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CLINICAL RECORD ---T3FRAPECTIVIIIMPOIERMITN- , • '., --.1! , , _ _ .8. Fate B of this form, SBO AR 40407;

the ncy is the Office of The Surgeon General. Mo. C.--3 vERIFY BY INITIALING

roannenta

MAKIONORMNOWS:ta".8 .:: INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION

ORDER DATE

CLERK' NURSE

RECURRING ACTIONS, FREQUENCY, TIME

14R DATE COMPLETED

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ALLERGIES: I. YES Li NO PRIMARY DIAGNOSIS:

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C---V;Cr-----. ..--r- 1--__ ADDITIONAL PAGES IN USE: NI YES NO

PAGP'n '

PATIENT IDENTIFICATION:

ACTION TIMES -,---- r. .i_' /1_) USE PENCIL. CIRCLE ACTION TIMES

L-.: CO( (L) --- t/i D 8 9 10 11 . ' 12 13 14 15

E 16 17 18 19 20 21 22 23

rf A reine• 12-,, 4 n p.m. , ...

N 24 01 02 03 04 05 06 07

EDITION OF I DEC 77 MAY BE USED.

MEDCOM - 15841 ' • ,‘ . ‘ \ „ (\;.

USAPA 51.00

DOD-029230 ACLU-RDI 1634 p.1

Verify by Initialing

TRERAPEUTIC DOCUMENTATION CARE PLAN ■ (NON-MEDICATION) Mo Yr

Order Date

Clerk Nurse

SINGLE ACTIONS t Date to

be Done Time to

be Done lime Dona Initials

.4•

•

....

•

?

A

•: . :, ‘ .

Orden Date

mai Nu rse

PRN ACTION, FREQUENCY

INITIAL PROPER COLUMN FOLLOWING COMPLETION

TIME!DATE COMPLETED

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MEDCOM - 15842

DOD-029231 ACLU-RDI 1634 p.2

CLINICAL

VERIFY BY INITIALING

RECORD

CLEM NURSE

diggfintanaMEMOmak

s THERAPEUTIC DOCUMENTATION For u

the re meet a

CARE PLAN (MEATTIONS) e of this form see AR 40-407;

encs It the Office of The Surgeon General. MO. ED' e3 1N177 AL PROPER COLUMN FOLLOWING EACH ADMINISIRA770N

ORDER DATE

RECURRING MEDICATIONS,

. -e Ve.csop,„9,.;

HR DATE DISPENSED

DOSE, FREQUENCY

oc ry rt a i r 1 RI ■

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ALLERGIES: 1 YES MI NO PRIMARY DIAGNOSIS: A

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PAGE NO.

PAGES IN USE:

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DISPENSING TIMES

USE PENCIL. CIRCLE MED TIMES

7 8 9 10 11 . 12 13 14

15 16 17 18 19 20 21 22

23 24 01 02 03 04 05 06 n a cnonn 11C713 1 ren WI

USAPA

MEDCOM - 15843

DOD-029232 ACLU-RDI 1634 p.3

Pacu Intake

Site Amount

Post-Anesthesia Recovery score ADM 30' DIC Codes 200 Criteria

180

160 V

V V 4,

•4/ )60 140

120

V 100

•

!COMM on ievene

Name

DEP/4117R KLINIC

DATE

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)

MEDCOM - 15844

Previous edition is obsolete USAPPC 5100

DOD-029233

-411,MEDICAL RECORD-SUPPLEMENTAL MEDICAL DA Fm use of this form. see AR 40.66; the prooherst agency is the Office of The Suwon Goners!.

Post-Anesthesia Care Unit (PACU) Flow Sheet

• c rJ Anesthesia Type5

(C,licl Gev.;-1pinal Epidural 090-t .1 IV tion Nerve Block ?

A! - I. A OR Intake: Crystalloid c4ISFO Colloid

ri-....11Mg .- Meds/Times: :Vein OR output: UOP gs EBL itr1/41V ,"

X-rays:

jOTSG APPROVED Wald

Drains Hemova

NG

-tube Foley

TLS

By Infused

Labs:

T TITLE

Date: Time In: Allergies: Pre-op V/S: Procedures:

22D

Airway Nasal Oral

T ch

ther

Activity (2) Moves 4 Extremities (1) Moves 2 Extremities (0) Moves 0 Extremities

Airway (2) Cough, Deep breath (1) Dyspnea, limited breathing (0) App

Blood Pressure (2) SBP=/- 20 of Pre-op (1) SSP =/- 20-50 of Pre-op (0) SBP al- 50 of Pre-op

Consciousness (2) Fully Awake, audible eying (1) Atousable to verbal or pain

Color (2)Baseline color & appearance (1) pale, mottled. jaundiced (0) Cyanotic

Circulation (Peds < 5 Years) (2) radial Pulse Palpable (1) Axillary palpable. not radial (0) Carotid only reliable pulse

111111111l facity)1Plika • tries give:

❑ HISTORYIPHYSICAL ❑ FLOW C

❑ OTHER EXAMINATION ❑ OTHER gp•ari OR EVALUATION

❑ DIAGNOSTIC STUDIES

TREATMENT

Pre 0. Meds Histo

Time

Time Sol•tion

Methods 4

Sa02

Fi02

240

80

60

•

A

a • /81' A 11/4

A e •

40

20

AIRWAY Ambu

BB = Blow-by M — Mask FT = Face Tent RA = RoomAir NC = Nasal Cannula

WS X =A-line BP - =Cuff BP

= Pulse

TEMP S = Skin 0 = Oral A = Axilla

ympanic R = Rectal

LOS C= Cervical T = Thoracic L = Lumbar S Sacral

11111111MMEMEF TOTALS: Must be 9 or greater to D/C. otherwise needs anesthesia approval for DIC.

RR

T

Paten teaching done; Wound Care. Pain Management. C, & DB,. Incentive Spirometer, Comfort Measures

Safety: SR up X 2. Falls Precautions. Privacy Maintained

Time Pain (0-10) LOS

ACLU-RDI 1634 p.4

DOD-029234

MEDICATIONS Allergies: Time Pain

1-10 ----f3macip Medication & Route Pain

1-10 WE By

156 Pereocci i:' , f-1: tr a

NEUROVASCULAR Time Site Range

Of Motion

Sensory P • Cap Refill

T Color

Adm

15'

30'

45'

60'

D/C

Movement/Sensation: + = present.- = absent Temp:C .. Cool, W =Warm Pulses: P = Palpable. D= Doppler, A = Absent Color: C = Cyanotic,

Capillary Refill: B= Brisk, 5= Sluggish P= Pale, Pk= Pink

C-SECTIONS Adm 15' 39%167— 60' 90' DIC

Fund. Height ,----"---

Lochia

Peri -

und. Cond. '

DRESSINGS Time Location Type Drainage

Adm MIEMMIILMMMIIIMPr".:411111111 30' ValrealMIMMIMIIIIIIRAMM% twarareffs /Miff= I 41111111M1111 D/C .____Mt-Mtf..rnIMEINVIIIIIIIIIIIMIIIIp

- CARDIAC RHYTHM _..

Time lAythm 1 Symptomatic? m Strip Run?

-----------

.

V WA 73-E

MEDCOM - 15845

NURSING NOTES

daiz'POMP,MAIE

rioet,iliar*

Aiikt

II

Jill

•jo.

amolt, (aa osiz. Ns z -,010

),a5c4 hv 57=ei/

r

Ay.

PACU OUTPUT

Time Source Color/Appearalve- Amount

Additional Data: '74,41-Yeza/y-- rTar erred To:

Report Given To: Transferred Via: WIC Transferred By: Cleared lAW Recovery Room SOP 8-3 Charge Nurse Signature:

PARS: iD RR: /9 Sa020

Output:/

Ambulance

Discharg = Criteria: Date: 3Time,: BP: ) T: OHR: Pain _.:V) (0-0): Intake:

ACLU-RDI 1634 p.5

[SID 14f ^f Time Pain (0-10) L

600 1-/ lo '110

a 10 Zit

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DA1 Foe use of this term. see AR 40.66: the praponeni agency • the Office of The Surgeon General.

REPORT TITLE

wr s- 14-1‘56

Anesthesia Type (Circle)): M, pinal Epidural IV

OR Intake: Crystalloid S.(P . n Nerve Block ...1)43

OR Output UOP cy're,, / '''dS Fe Meds/Times:


History Phi- stirti-OP

OTSG APPROVED Ware)

Drains Hemovac

NG JP

Date: A4,6. 0 3 Time In: 15P Allergies: IX.P)ir Pre-op V/S: I .47 (11 Procedures: tt.1.4^'0.94

44 Pre Op Meds

Airway Nasal Oral ETT

Trach

Other

Time ez.

%Tx--

Sa02 cis

F102

240

220

200

80

20

Methods

180

140

120

100

RR

160

A A

CA

•

V

•

A

grk

•

414

•

17

A

V'

•

V

t5

a

Ix

a

k.,t)•-- .2_

Pacu Intake Time

i 15 Solution

21-14- Amount

Mg= Site •

DIEM By

IIMILI

X-rays: 1J I Or- . Labs:

Post-Anesthesia Recovery score Criteria ADM 30' D/C Codes Activity (2) Moves 4 Extremities CO Moves 2 Extremities (0) Moves 0 Extremities

Sit.. 2, *A. AIRWAY

A =Ambu BB = Blow-by M — Mask FT = Face Tent RA = RoomAir

Cannula

VIS X =A-line BP - = Cuff BP

= Pulse

TEMP

0 = Oral S = Skin

A = Axillary T = Tympanic R = Rectal

LOS C = Cervical T = Thoracic L = Lumbar S = Sacral

any (2) Cough. Deep breath (1) Clyspnea. Smiled breathing (0) Apnea

,-- 1.----

Blood Pressure (2) SBP 4- 20 of Pre-op (1) SBP 4- 20

4 -50 of Pre-op

(0) SSP - 50 of Pre-op q ...- -

NC = Nasal

Z .- Consciousness (2) Fully Awake, =Stile crillig (1) Arousable to verbal or pain

(

Col or (2)Baseline coke & appearance (1) pale, mottled, jaundiced (0) Cyanotic

#2.......

-

2-/--

Circulation (Peds < 5 Years) (2) radial Pulse Palpable (1) AtellarY Paloable, not radial (0) Carotid only reliable pulse

TOTALS: Must be 9 or Ater to D. otherwise

INC, needs anesthesia approval for

. .

ci I

icommue or averse! DEPARTMENTISERVICEICLINIC

1G4 (Do) DATE

5 NFL 3

Patien T. C. & OB,. Incentive Spirometer, Comfort Measures Safety: SR up X 2, Falls Precautions. Privacy Maintained

PA or wilier entries give: Name — laS4 fiat, middle; grade; date; taelityl

❑ HISTORTIPHYSICAL

❑ OTHER EXAMINATION OR EVALUATION

1:3 DIAGNOSTIC STUDIES

❑ TREATMENT

FLOW CHART

OTHER xs=rtri

Previous edition is obsolete USAF V2.00

DOD-029235

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)

MEDCOM - 15846

ACLU-RDI 1634 p.6

30' I.

60' It :1/4 4 It U

ti 14 D/C

NEUROVASCULAR Range I Sensory P Cap

Of Refill Motion

Time Site T Color

(t)utwitb I (U Adm

15' ®1*6

45'

9(Y

Movement/Sensation: + =present,- =absent Temp:C =Cool, W =Warm Pulses: P =Palpable, D =Doppler, A= Absent Color. C = Cyanotic,

Capillary Refill: B= Brisk, 5= Sluggish

P=Pale, Pk =Pink

Adm 15 45' 60' 90' D/C Fund. Height

Lochia

Peripad#

Fund. Cond.

Discharge Criteria: Date:5 At4 03 Time: MC PARS: BP: ( 74(1-c T: Cri OA, HR:ll 0 RR: 17 Pain Level at =10-101: Intake: 50C C Output: Additional Data: SO • Transferred To: Report Given To: Transferred Transferred Cleared IA Charge Nurse Signa

sp• MEDICATIONS

Allergies: Time Pain

1-10 Medication & - flosanp

Route Pain 1.10

I/E By

/

Al° .

DRESSINGS

Time Location Type Drain age

Adm (i'l 4011 Faktits) ACe VRt't

30' ,, „ 1. k 1 1 •

60' x i t k it . (7

DIG `` i., N k P.

PACU OUTPUT

Time Sour Color/Appearance A

ef

mount

CARDIAC RHYTHM

Time ;;•7 Rt(y.thm Symptomatic? Rhythm Strip Run?

,•

WAMC OP 173-E

NURSING, NOTES

woAL '11 I mom ,idete Ibkiw- .,gLu 4._ ace La? l li ast kJ ' . Z 3 jec c. 4tta, 0/

Gu w..4.4.g9 (Arc. e„ RNA Lx-oe.

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bk CiA Att* 41/i4tirc

Susi

MEDCOM - 15847

DOD-029236

ACLU-RDI 1634 p.7

2nd PRIORITY MODERATE A789849

Mass Casualty Incident Tag ©Eastern PA EMS Council - 1997

(A)

Patient Name (if know

Notes/Treatment i (1 ;

To be given to:

TRANSPORTATION OFFICER

Hospital

DOD-029237 ACLU-RDI 1634 p.8

2nd PRIORITY MODERATE

DECEASED Minor Injuries/Illness:

Moderate Injuries/Illness:

1 Life Threatening Injuries/Illness

D co-worker injured LI uncontrollable emotional disorder

LI OBVIOUSLY DEAD (D.O.A. - D.A.S.)

Mass Casualty Incident Tag Developed for

Triage and Patient Management et Eastern PA EMS Council 1997

(610) 620-9212

Additional Information:

4 •4

MEDCOM - 15849

DOD-029238

ACLU-RDI 1634 p.9

MEDCOM - 15850

as required)

Crtnxit ► tlor 11,11A n On

1 . REPORTING MTF ml11/

2.m u

IIKfF LOCATION gillar ADMISSION AND CODING INFORMATION

For use of this form. see AR 40-400; the proponent agency is MSG

1 I 2 I 3 4 5 6 7 8 (State or

Code.) Country 1

A 1 I Zs) 1.,-,, — .,,,,,..,,

-Z.,.. 3 . REGISTER NUMBER NAME (Last, First, Middle Initial) 4. PAY GRADE 5. SEX

9 10 11 1213 14 15

0 cpv\i 44- ,_ ts_e

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_0 0 t 14 t 1,2,4-xi—I B . DATE OF BIRTH (YYYYMMDD) 7. AGE ATA • . • . RACE 9. ETHNIC RELIGION

U Ai

19 20 21 22 23 25 26 27 28 29 30 31 BACK-

Z- 12 '1 -- -- z "Z --1 11.

y GROUND

10. LENGTH OF SERVICE ETS FMP 12. SOCIAL SECURITY NUMBER

32 33 34 35 36 37 worm 40 41 42 43 44 45

HOUR 0 - •

ADMISSION CC' '— (-

------, q 9-

ORGANIZATION (Active Duty Only)

____-------.)

13. MARITAL STATUS

46

14. FLYING STATUS 15. BENEFICIARY CATEGORY

.

18. ZIP CODE OF RESIDENCE

47 48 49 50 51 52 53 54 55 56 57 58 59 60 81

-7 I g -E L g_ 17. UNIT LOCATION (State or 18 MOS 79. TAAUMA PREV . ADMISSION

62 63 Country Code/

64 66 67 68 1

69 1 70 71 1

YEAR ,

— ,_____

20. SOURCE OF ADMISSION/ AUTHORITY FOR . ADMISSION ,.....„

\ ,--,, ✓ ^ ( 77) , Z..— _„,

WARD

T C ud Z-

NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

VI Ne--_. 72 ADDRESS OF EMERGENCY ADDRESSEE (Include DP Code)

L fill

N

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21. 1. TYPE OF DISPOS

FACIL

. M

TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

U / .M.:- F TRANSFERRED TO 23. DATE OF DISPOSITION IYYMMDD)

73 74 1 75 76 17-..,, 78 1 79 80 81 82 83 84 85 86

MEI 5 0- i , , 0 -

24. CLINIC SVC - ADMITTING 5. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION IYYMMD0.1 1 87 i 88 1 89_ j

1 90 j 91 1 92 93 94 95 96 97 98 99 100 101 102

7—Ffri .11 LA I ; a 3 & .4 Itan

27. LOCATION Of OCCURRENCE (Battle

28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION (Y V MMD 0)

103 -----;—.. Casualty Only)

104 105 106 1 107 108 1 109 110 111 112 113 114 115 116

_ ___ FOR LOCAL USE , - ....

--- ,,

05(A) 4 cfevx OK CD kaNtol D ,i; i Pow. 5r-di . --itaCern s'rol rfltiq A--?-r-i 9

—7q.-3 1 •

DOD-029239

ACLU-RDI 1634 p.10

t'

INPATIENT TREATMENT RECORD COVER SHEET For use of this form, see AR 40-400; the propone t agency Is 0"fp3

(e J - REGISTER NUMBER

0° i LHO5 NAME (Last FIrs1

lit)

3. GRADE ADMISSION REMARKS

4 sax

in .....—,...

5. . AGE

3

6. RACE 7. RELIGION

--...—.

8. LE 1

10. PREVIOUS At

11. jr n Ll

12. SSN ., 1 , ORGANIZATION . 14. WARD

7c o l's2_ Lk L 15. FLYING

STATUS

ki 0

16. DSG

. BEN

i<,..7.9_1)

18. BRANCH/CORPS 19. UIC/ZIP 20. TYPE CASE

1 4 1 +1- 21. SOURCE OF ADMISSION/AUTHORITY FOR -ADMISSION - ---

I)recf-Pom :ER 24 NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

22. HOURS OF ADMISSION

1130 23. CLINIC SERVICE

A-5A- A - U 13Nt.,

25. TYPE DISPOSITION

/0

26. DATE OF DISPOSITION

I it A Vi 27s. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)

0 oy._.-

27b. TELEP ONE NO. 28. DATE OF 7 ADMISSIO

'b. PVIA

ADMITTING L OVICER e r.} l. (.....

29. NAME AND LOCATION OF MEDICAL TREATMENT FACILI

n -(2 30. DATE

ADMISSION 32. UNITS OF WHOLE BLOOD/

COMPONENT TRANSFUSED

31.

Check If Continued on Reverse

33. CAUSE OF INJURY

G-.ThtZ

34. DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES

DSC: Gado --1-0 10 Knce, /6D -pa-i-e,110,r Cfpgn 'TX

35. Total Days This Facility

ABSENT SICK DAYS b. OTHER DAYS C. CONV, LV/COOP CARPS

d. SUPPLEMENTAL CAR S

e. BED DAYS I. TOTAL SICK DAYS

36. Total Days All Facilites

e. ABSENT SICK DAYS b. OTHER DAYS C. CONY. LV/COOP d. SUPPLEMENTAL CARE DAY CARE DAYS

0

' • BED DAYS

- Al

I. TOTAL SICK DAYS

SIGNATURE OF ATTENDING MEDIC DICAL RECORDS OFFICER

n A Ohl •sa -, a

MEDCOM - 15851 USAPPC V1 10

DOD-029240 ACLU-RDI 1634 p.11

IGNATIME OF PHYSICIAN

VtfrENT•S 10ENTIFICATION (Po, trped or written entries give N

Ian:. &ie• ame grade: dart; hospital or medical Medley)

ORGANIZATION

VVAIRO NO.

ABBREVIATED MEDICAL RECORD standsett Irons SOS

INTERAGENCY SERVICE,_ ADMINISTFIATION AND

RECORDS ON MEDICAL RECORDS PIRM (41 CM) 201

-45.505 OCTOBER 1976 539-108

MEDCOM - 15852

MEDICAL RECORD -"

-- ABBREVIATED MEDICAL. RECORD PERTINENT HISTORY,

CHIEF COMPLAINT, AND CONDITION ON ADMISSION

AB (

r dotr of rulmipaioni

PHYSICAL EXAMINATION

PROGRESS (A:Hie/date of diadletet and lima d(optosie

ACLU-RDI 1634 p.12

AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD

PROGRESS NOTES

DATE NOTES

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RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S 10 NUMBER ISSN or Mal

LAST FIRST - MI

DEPARTJSERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

PATIENTS IDENTIFICATION: (For typed or mitten sorties, gim• Name -lest. lost, middle;

IID No Of ..SIX Sec Date of Birth; ReoldGrede)

REGISTER NO. WARD NO.

PROGRESS NOTES

3

Medical Record

STANDARD FORM 509 (REY. 51101H0 Prescribed by GSAACMR FPMR I4ICFRI 101.11.21:13(b)1101

USAPA 41 .00

MEDCOM - 15853

DOD-029242 ACLU-RDI 1634 p.13


PROGRESS NOTES MEDICAL RECORD

DATE /14 av_71.4 11- NOTES

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$ 100 19 47 %..t. , r "7 4.,A--6,--, , z,-,1 IA- hip h.

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DEPART.ISERWCE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

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PROGRESS NOTES Medical Record

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DOD-029246 ACLU-RDI 1634 p.17


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DOD-029248 ACLU-RDI 1634 p.19

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DOD-029249 ACLU-RDI 1634 p.20

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Mechcal Record

STANDARD FORM 509 MEV. 51199G1 Practised by GSAGCMR FPMR CFR} 101.11.2031b1110

USAPA V1.00

MEDCOM - 15867

DOD-029256 ACLU-RDI 1634 p.27

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Merkel Record

STANDARD FORM 509 (RTC slum Prescribeil by GSAACMR FPMR Nun) lot.m.zonoxi

USAPA Y1.00

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MEDCOM - 15868

DOD-029257 ACLU-RDI 1634 p.28

(Continue on reverse side)

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1 PATIENT'S IDENTIFICATION (For typed or written a. s ik: e—ia fir t. middle; grade; rank: rata: I REGISTER NO.

hospital or medical fa

NURSING NOTES

Medical P.ecorC

MEDCOM - 15869 2i/L-:) , 20:1 -

DOD-029258

NSN 7540-00-634-4123

510-112

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ACLU-RDI 1634 p.29

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Include medication and treatment when indicated A.M. ! P.M.

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STANDAR

MEDCOM - 15870

DOD-029259

ACLU-RDI 1634 p.30

2

12 /(D3 MEDICAL RECORD I


CHRONOLOGICAL RECORD OF MEDICAL CARE

DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

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PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN;

Date of Birth; Rank/Grade.)


CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMA (41 CFR) 201-9.202-1 USAPA V2.00

EP MEDCOM - 15871

DOD-029260 ACLU-RDI 1634 p.31

NSN 7540-00-634-4116 600-108

HEALTH RECORD . CHRONOLOGICAL RECORD OF MEDICAL CARE

DATE SYMPTOMS, DIAGNOSIS, T RE ATME NT, T R EAT I NG ORGANIZATION (Sign each entry)

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RECORDS lool MAINTAINED

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RELATIONSHIP TO SPONSOR STATUS RANK/GRADE

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DEPART./SER VICE SSN/IDENTIFICATION NO. DATE OF BIRTH


MEDCOM - 15872

STANDARD FORM 600 (REV. 6-841 Prescribed by GSA and OAR FIRMR (41 CFR) 201-45.505

DOD-029261 ACLU-RDI 1634 p.32

DATE

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

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MEDCOM - 15873

DOD-029262 ACLU-RDI 1634 p.33

NSN 7540-00-634-4176 AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE

DATE SYMPTONS, DIAGNOSIS, TREATMENT, TljaTING ORGANIZATION (Sign each entry)

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MEDCOM - 15874


STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/1CMR FIRMA (41 CFR) 201-9.202-1

DOD-029263

ACLU-RDI 1634 p.34

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MEDCOM - 15875

DOD-029264 ACLU-RDI 1634 p.35

NSN 7540-00-634-4176


MEDICAL RECORD I CHRONOLOGICAL RECORD OF MEDICAL CARE


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STANDARD FORM 600 IREV..6-97) .Prescnbed by GSA/ICMR FIRMA (41 CFR) 2019.202-1

MEDCOM - 15876

DOD-029265 ACLU-RDI 1634 p.36

DATE SYMPTONS, DIAGNOSIS, FREATMEN , REATING ORGANIZATION (Sign each entry!

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MEDCOM - 15877

DOD-029266

ACLU-RDI 1634 p.37

NSN 7540.00-634-4176



DATE I SYMPTONS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

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cti 55-1.-u-tiLte-, -t.u..6( 5

hc-5 UAJLA-

e-Cufi5 TYlk

A-Apet44-4--<-1:v-

(`-e-C Ict54-C

1))/D'i" mA..,..44--( V445

in, 6(4 2 ,e4et

(03 1(c v R t

ETOH GLU MICRO

TIME RESIDE NT/MEDICAL STUDENT SIGNATURE AND STAMP ACTION

STAMP

L DIAGNOS yi,,„fa ( /-_s fx-34.ef, kdv;,,,‘„ %cD

Flt (pdara- 41t-e-A- -c7 P; ig-PA44-*

PATIENT'S IDENTIFICATION (For typed Of written entries, give: Name — last. first, middle: ID no. (SSN or other); hospital or mad/cal facility)

EMERGENCY CARE AND TREATMENT (Doctor) Medical Record

STANDARD FORM 558 MEV. 9-96) Proscribed by GSA/ICMR FPMR 141 CFR) 101-11.203(141101

MEDCOM - 15887

CONSULT WITH

X,/ nAiwrD (v

DOD-029276

ACLU-RDI 1634 p.47

C. INTEG,IJMENT N7Potential impairment of skin

integrity due to: ✓ I) Intraoperative Immobility

ESU Pad Placement 3) Positional Aids

'4) Prosthesis \-75) rooline of Prep Solutions

Pt. will not exhibit signs of impairment of skin integrity (e.g., reddened areas).

rre-' Utilize pressure preventing devices on OR table and accessories.

Check for proper positioning and support to maintain good body alignment.

,e' Pad pressure points. p-- Place ESU ground pad on non compromised skin surface area.

,z' iteeRprep fluids from pooling.

VERIFICATIONS AT HOLDING AREA ! ID/Allergy Band ! Dentures Removed ! H & P

! Contacts Removed NPO Since 1)11 1\1 ! Jewelry Removed

! Li1-1CGiLMP

! Body Pier= Rernmel. ! Consent/Blood Transfusion Signed/Witnessed/Dated ! Surgical Site/Consent verified by PUAnesthesiaiSurgeon ! Contact Precautions (Y) !

9. PATIENT'S IDENTIFICATION: (For typed or written entries give: Name- last, first, middle; grade; date; hospital or medical facility)

2. KNOWN ALLERGIC SENSITIVITIES (e.g.. Iodine, Tape, Medication) 0 NKDA 0 PCN 0 LATEX E. IODINE 0 TAPE 0 FOOD REACTION:

WA1C-11.01).)v) 3. PREVIOUS SURGERY ( ) NO ( 1 YES (type):

WAAL-IA.0W In

1. AGE: 20 s

HEIGHT: u...v‘Y—Aow'r\

WEIGHT:

- • P'REOPERATIVE/POSTOP WE NURSING DOCUMENT

FOR Use of this form. see AR 4-107; the proponent agency is The Office of the Surgeon General

4. PROPOSED SURGICAL PROCEDURE: So w

0 FIVA. r24-el1a-r-4- G s

Dentures 6. PATIENT PROBLEMS AND NEEDS

A. PSYCHOSOCIAL NV- Potential for anxiety related

5. ADDITIONAL INFORMATION: Tobacco 1 ppd X yrs. Body Pier ETOH I. Implants Glasses/Contact (Y) (N)

(Previous surgical and medical history) Skin Condition vo.4.11ipte bn.k.ises r_ sc.eatctki_ti ting 0

Diabetes (Y) (N) ROM ASA/Nlocrin w:72 hrs (Y) (N)

0

Respiratory Disease (Asthma , COPD) (Y) (N) Anticoagulants (Y) (N) Hypertension (Y) (N) Herbal Medicines (Y) (N) MEDS: * ►u*

7. PATIENT GOALS AND EXPECTED OUTCOMES . S. OR NURSING INTERVENTIONS Allow pt. to verbalize freely.

cr Explain OR environment and answer questions regarding surgery. % Offer comfort measures. (e.g.. warm blanket. touch). 5,--Explain all nursing procedures before

they are done. .z"- Remain with pt. whenever possible.

Maintain family interface. Parents to stay with pt.

to: `-'1) Surgical Procedure &

Operating Room Environment 2) Separation Anxiety

(Child) ✓ 3) Surgical Outcomes

Pt. verbalizes any specific anxiety. 9.--Pt. Exhibits relaxed body posture.

B. AERATION \-7Potential for respiratory

dysfunction due to: I) Positioning.

\---" 2) Effects of Anesthesia N.73) MedicallSmoking History

t. will be able to breathe without difficulty during immediate intraoperative phase .

.„.e" Offer to elevate head of litter or ofo ffer pillow.

/2--- Observe pt. while awaiting surgery for stuns of distress.

Assist anesthesia during. Intubation and extubation.

D AfORN1 5179, JUN 91 • Previous editions are obsolete. • MEDCOM - 15888

DOD-029277

ACLU-RDI 1634 p.48

"Ilk will exhibit signs of adequate tissue perfusion (e.g.. color, warmth, pedal pulse.

... PATIENT GOALS AND EXPECTED OUTCOMES 6. PATIENT PROBLEMS.AND NEEDS ckAcuLATIOtk • •

\/1ioienifattoi. innilequ'ate tissue perfu,n due to:

Intraoperative Mobility positioning Existing Disease Safety Devices Hypothermia

R NURSING INTERVENTIONS e. Check for support stockings or ace ‘NTaps. If none, check with doctors.

Check that safety straps are correctly applied. / Offer pillow for under knees. o Place and take down legs from stirrups with slow bilateral motion.

, Check that rings and all body niercina has been removed

DATE

SKIN INTEGRITY: Bovie Pad Site: 2( Clean and Dry Drowsy Sleepy ❑ Incubated

n Extremities 2 Moves Upper Extremities ❑ Transferred to liner with roller due to spinal PREPARED BY 13. POSTOPERATIV

'\7

11. POSTOPERATIVE EVALUATION: LEVEL OF CONSCIOUSNESS: G A&O LEVEL OF ACTIVITY: Moves

12. PREOPERATIVE EVALUATIO (Signature and Titl

DATE: 1 \kk BY (Signature and Tit

DATE: -1.p,

C. Red D NiA SING DRY & INTACT: (NI ATHING EASY: N)

REVERSE OF FC -)9, JUN 91 MEDCOM - 15889

E. NEUROMUSCULAR CONTROL E.1. N..." Potential impairment of mobility due to:

✓ 1) Pain intrionerative Hazards

3) Prosthesis ✓ 4) Positioning.

Transfer pt. to/from OR table E.2. N."-potential discomfort due to:

Length of Surgery Positioning

3) Arthritis

KN. will be transferred to OR table without difficulty.

„e1 Pt. will not experience unnecessary physical discomfort.

Air Have sufficient people available for transfer. o i Insure proper body alignment. ,d Allow patient to lie in position of comfort while waiting for surgery.

Offer support (i.e.. pilloWs. bath towels. etc.) for positioning.

F. SPECIAL SENSES F.1. ✓Dtrainished visual perception due to being:

■-.11. 1) Pre-Medicated 2) \V 0 Glasses F.2. \.../ Potential for decreased communication due to:

1) Diminished Hearing Language Barrier — 4)"..te c__

F.3. Potential injury due to dennires:

4) Cans 1) Urine- 2) Lower 5) Crowns 3) Bridges

AC Pt. will be made aware of surroundings • prior to anesthesia induction.

9- Pt. will be transferred safely to OR table. Pt. will be able to understand instructions.

7 Minimize danger of injury during intraop period.

.c( Introduce self. Keep pt. informed as to where he. she is and what is happening.. • Inform pt. in which direction to move and assist if necessary.

,e1 Speak clearly and slowly. /. .Address pt frc-rr. • Validate pt.'s understanding of verbal communication. c Verify removal of dentures.

G OTHER PATIENT PROBLEMS NEEDS. Or continuation of above problems/needs.

OTHER PATIENT GOALS AND EXPECTED OUTCOMES. Or continuation of above goals and outcomes.

OTHER NURSING 1NTERV.ENTIONS Or continuation of above interventions

10. OR NURSING INTERVENTIONS COMPLETE D/ADDITIONAL INTRAOPERATIVE INTERVENTION S NOTED.

DOD-029278

ACLU-RDI 1634 p.49

rei.--i • ,.. ... ''.:7- .• .INTRAOPERA. atr • ;,-..' ,m,...i:..:,-4. ;. r . • ..i. . For use of this form, see AR 40-68, the proponent

)DOCUMENT . agency is the office of The Surgeon General.

A'.1E0.' :U - 7 , 3 Errwo.'OPERATING ROOM - . yrAP.-.- - " "...--- . BY . fitleStife-Sia :3' DATE ' • TIME PATIENT ARRIVED IN SUITE 1 IN1,1 () 03 I -1

2. PATIENT IDENTIFIE RECORD VERIFIED BY i L../ 4. PATIENT IN ROOM

TIME 0 g 1 1

ED AND PROCEDURE

,--;, '?, CA .. 2 f\ \ NUMBER d-- /

5. PREOPERATIVE EMOTIONAL STATUS

❑ ANXI OUS • CALM

6S l.x.)

• EXCITED • CRYING • ANGRY ❑ WITHDRAWN

calk\

al OTHER (Specify)

COMMENTS: SA)

wo -f. rfm• 9 to u..,.. ifyls ,z,,.

Pia 'D‘siti 6. NURSING PERSONNEL

ASSIGNED SCRUB

5 N RELIEF SCRUB

ASSIGNED CIRCULATOR

la RELIEF CIRCULATOR

. sae an paolded ..x-r), 7. POSITION AND POSITIONAL AIDS (Specify)

IA SUPINE 0 LITHOTOMY

COMMENTS: .00-• ..Nf ■Oti\li.C.

PE. .. skpkiksi on ,c(-. 7)i—Z-tbLsz ❑ KRASKE LATERAL:

aUl\r\ M9 1/ 111.. If \iY- 1

• PRONE ■ LEFT SIDE UP ■ RIGHT SIDE UP

inl 8. SKI PREPPASTOIOLN

PREP UTI;)

N (Specify) SITE: Left k-I2- BY WHOM: i 0- MM. SITE: BY WHOM:

. COMMENTS: 1\[ .b lutup9 Or Qaverst remiOn

HAIR REMOVAL

DONE BY:

METHOD:

❑

COMMENTS: Ni\-

YES • NO Dr, . 111111. OR DEPILATORY CLIP LQA-k.

`CIS or

■ RAZOR

Was 110-tf) 6 9. LOCATION OF EXTERNAL DEVICES

. _____ " Ate_47:02wgezi-...*-2:0:40irlif A _

------ft—kiiii.----_ viva=

TowniRt.....a.. G 300 .41.4, - Safe - . • = Tourniquet )1 - ? rtf) X c" PA/ 01

•_ / 1

LEGEND X Mad %,,,,,:orw,: 5,....-r-

t er 10 t COUNTS

Sponge

C = Correct I = Incorrect

Other • • First Closing Count

Final Closing Count SCRU CIR?KATOR

Yes IIII No Needle Sharp n Yes ■ No

Instrument ❑ Yes r.I No Other III Yes Z No

11. PATIENT IDENTIFICATION (For typed or written entries Name - Last, first, middle; Grade; Date; Hospital or Medical

nib

\( (1)C q

---

give: Facility;)

MEDCOM

12. ELECTROSURGERY DEVICE(S) IESU) [X' YES ED NO C.L.4...4 go

IX ESU NO: 14- Ca-a61 30 GROUND PAD:

IN ESU NO:

BRAND V1_ Zen atktte2At_.2.. LOT NO: kifiNQ -64/ c2005-.- 03

GROUND PAD:

U BIPOLAR NO:

q tRAkt . . ,a, to-rvNO:

— , 15890 ;

- I, I 0- ■ • ■-11O1-1 IS OBSOLETE.

USAPA V1,01

DOD-029279 ACLU-RDI 1634 p.50

13. PROST •SIS,1MPLANTS 0 YES- (E NO IF YES NAME: ID NUr-c.R: MANUPACTURER

14, • ---e-,2:f -4,'f.- th-Vr ''''' - . ri. _ : MEDICATIONS/ORDERS. --Z,L.,:,5; - ,..--. ,7: ,, IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)

6--- -;•-crA, ',•-;•; ,.,.- l'-,•_•-_ ,.:, ‘ ___

NO YES • MEDICATIONS. SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

AM=

J i-.

WOUND IRRIGATION YES 0 NO, TYPE(S):

0.9°4 1..161..A- Q. s .

OTHER ORDERS a TIME CARRIED OUT BY ,

PHYSICIAN'S SIG

6 ( (1) - 2_ 15. X-RAY IN IF YES, SITE

- • -j----------- YES D NO •

16. LABORATORY SPECIMENS SPECIMEN (S)

YES ❑ NO ac NAME NAME

FROZEN SECTION (FS) NAME • , .(,, ,

NAME YES • NO X

CULTURE (C) YES ❑ NO g

NAME NAME

NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)

T W-{ \ Op , -tstc ,CLA;LX` E 17. TUBES, DRAINS/PACKING YES NO • TYPE/SIZE 1 . reartrie.- bra ► fl

1 1' 2 . 3.

SITE ' 1-eict &ILL 2.

3 .

19. ADDITIONAL INFORMATION (.31b--Th•

SIM3e-0 C\ : Dc_ \D ( (-k) - 2_

-Ni\d3Nts... CY7 MIN .

r5

r.

Y e

k4ac. 51.-19 I VI i t-1 ,t7e.c.P 20. OPERATION(S) PERFORMED

I CIG. b 10 UA-JUL U1/43b1AM I L..J2, F7. lajc.44.4._

21.. PATIENT TRANSFERRED TO

1 C1X --- TIME

092 S. METHOD

a 1_ -V.? 1- , -4 ...

22. REGISTERED TU

I)NURSE

( Le S1GNA

el ' '41,

: - .i.s.,; ,. .

REVERSE OF DA FORM 5179-1, 0

MEDCOM - 15891

DOD-029280

ACLU-RDI 1634 p.51

as(

... I 4 , , . • ..f.v: ' .• INTRAOPERA, rDOCUMENT „sk

, • .Z ' ' RE ? a 9 r7/. .' l' - —7,.- For use of this for see AR 40-66, the proponent agency is the office of The Surgeon General.•

E ' "'-1 2.1g 7.0FITE PrOPERATING ROOM •., .

yiAt '....= • - ' BYAiry/Stilt WI \ cnvivcx 2. PATIENT IDENTIFIED, D PROCEDURE VERIFIED BY 1 LI--

a...DATE • , TIME

U

PATIENT ARRIVED IN SUITE

cli A;Al 63 et EX)

4. PATIENT IN ROOM

TIME D'I 00 NUMBER — 4. 5. PREOPERATIVE EMOTIONAL STATUS

2 CALM

COMMENTS:

❑ ANGRY ❑ OTHER (Specify) ■ ANXIOUS ■ EXCITED ■ CRYING • WITHDRAWN

6. NURSING PERSONNEL

. , ..

ASSIGNED SCRUB

rj RELIEF SCRUB

ASSIGNED 'CIRCULATOR

RELIEF CIRCULATOR

7. POSITION AND POSITIONAL

21 SUPINE Vr:Cir.....r.

COMMENTS: tt.-C1 rho"..

AIDS (Specifyy 4 q

❑ RIGHT SIDE UP _. ❑ , KRASKE, LATERAL: Eil LEFT SIDE UP , C3-A",. .A.C%-^4 ‘,....Lck t_Irlgt.oktk ry -. . °c.v.-v. ottiv^:t 0 t ^S elIcke-'`•"-

I rec,,, Alt-sr_ eiviro.,,t.c4 Inl. •crIAArzesv., ,t-a......,24ret-tct

• LITHOTOMY U PRONE izi 0 CIA../5...=,,_J .4..A.".o.........

cto° JIL... ,„.

c..,..„,.,,c,e,e,...„.,..“,

8. SKIN PREPARATION .. .• ; ■ . HAIR REMOVAL II yES 0 NO

❑ NURSING UNIT

❑ RAZOR

PREP -*LOTION (Specify) E, cAck'VE4., SIT -1 BY WHOM: SITE: BY WHOM:

COMMENTS:4Agr y ON- sk.A.;" A' r> A.A.(4.-A.,

DONE BY: ■ OR METHOD: ❑ DEPILATORY

• CLIP

COMMENTS:

9. LOCATION OF EXTERNAL DEVICES

. •

.

. , I

1

-- Safety

) ,.:cft.

...

--

lekc olio

rarfirr- ► ftlataltkont•fit"

= = Tourniquet(

e .1

i ... P 1 . •

LEGEND X Ground Str =

te

Pa

10. COUNTS

ponge •

C = Correc = Incorrect "r.......A.A-L9. .

U

Other' •

L IA

First Closing Count

C

Final Closing Count

C C

SCRUB CIRCULATOR Yes III No

Needle Sharp bn Yes '1111 , No

Instrument III Yes No

Other ■ Yes No 1\i n N Pk 1\\ Y

11. PATIENT IDENTIFICATION (For typed or written entries Name - Last, first, middle; Grade; Date; Hospital or Medical

41- Illr T cAA?— 6VU)

l't

give: Facility;)

t'

AC nrs CNR A

12. ELECTROSURGERY DEVICEIS) IESU)

0 ESU NO: VG `••- (-U2-

• YES XN

?-- 4 3 (et 0 14-V1"

GROUND PAD: BRAND VI,- k?----- Y IAL9,;(*.-,a. LOT NO: 68 9 3 & Z.- s-eS

ii ESU NO:

GROUND PAD: BRAND

LOT NO:

■ BIPOLAR NO:

1 5892 DA FORM 5179-1, OCT 87

REPLACES —.-. . ...-IICH IS OBSOLETE. USAPA V1.01

DOD-029281

ACLU-RDI 1634 p.52

13. PROSTHESIS, IMPLANTS IN YES vvkc+...0-1 -Tv<>0 Sti- cr∎ S ► O92 1S0 ( 4 .0 0,-,,,,,, cct.,-,c..e.e.1-0,s sr-••r-3-4-Qs

k0 'A 3-C- K t

■ NO IF YES NAME: ID NUMBER; MANUFACTURER to csi\e... c rks. 4 OSZZ (CI

2:> ic 1 • 0, S Y: IC

z teLos Lko-t-.),-- x 3

14. - ..41,-.,444000tamigenti MEDICATIONS/ORDERS WiatIMAIMW,4051M4,06040Mgati

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES ❑ NO DI t

,MEDICATIONS.SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY '

•

WOUND IRRIGATION kci YES • NO, TYPE(S): •

0,9 °/0 NO■.C.e- 1

OTHER ORDERS TIME CARRIED OUT BY fl

K

PHYSICIAN'S SIGNATURE

15. X-RAY IN OPERATIN

YES NO

IF YES, SITE

Wi..., C' OWtAl■-■

16. LABORATORY SPECIMENS

SPECIMEN (SI

YES ❑ NO 71

NAME NAME

FROZEN SECTION (FS)

YES ■ NO i I

NAME NAME

CULTURE (C)

YES ❑ NO l ,

NAME NAME . - . '-

NAME NAME NAME

NAME NAME 18. DRESSING/IMNBIUNON (Specify)

1-14^-‘115 ces.

ya,...A...‘' y . A- €;"3: ' A-62-Wvekr,

,,..e...n 0 \r,4-e_eA,

17. TUBES, DRAINS/PACKING YES 21 NO ❑

TYPE1S1ZE

' Li,) hew, ovw. 2.

'

. .

SITEci--) .z.N

kwit 3.

19. ADDITIONAL INFORMATION

kAJNI tA

Al/\)-V “)'‘: MIMI

TO.4.."......A.Ci LA.-t.t .1.‘ OcitZ-C

1/ ti X,

oov; c 1.-.0' t.4 -C- Cil1/4 -- 04) 5i/ I A 20. OPERATIONS) PERFORMED

'S- -t- C9 kV\ek,

OR t T- g pc\ i-e-aGL,

21. PATIENT TRANSFERRED TO / \

CAA 4 ( (0) - /-- 2

*71- 1 itlj

TIME S-e...€

-b/Mgcl ,,:. ,.

METHOD ,_ ...::::.e.' ' ..'kt- c.. g , -4:,,L.... „Po. ' t.-„, F.

.:.i,.., , , - - - . ,...7.7-317-7---r--- 7-'--. 7.-"::;t713r7'' 'fft,

REVERSE OF

MEDCOM - 15893

DOD-029282

ACLU-RDI 1634 p.53

. INTRAOPERI

MEDICAL RECORD (e. ) ?-i0CUMENT

7.i. For use of this form, see AR 40-66, the prop. J:,iicy is the office of The Surgeon General.

1. PATIENT TRANSPORTED TO OPEFtl.riNG ROOM , VIA V. 0-4-A/ BY itoughtmokl 0.1S tiVvIS

2. PATIENT IDENTIFIED, OCEDURE VERIFIED BY CV' b (,) - 2-

3. DATE TIME PATIENT ARRIVED IN SUITE

t.?, iCkk15,02 kOZ 0

4. PATIENT IN ROOM TIME 10 0 NU


gl CALM ■ ANXIOUS ■ EXCITED ■ CRYING - ■ ANGRY ■ WITHDRAWN ■ OTHER (Specify)

COMMENTS: Allergies: —le-AC-Ok)-


ASSIGNED SCRUB

S,5 C-71 RELIEF SCRUB

V.) i

ASSIGNED CIRCULATOR

RELIEF CIRCULATOR

7. POSITION AND POSITIONAL AIDS (Specify)

SUPINE ■ LITHOTOMY ■ PRONE ' IP KRASKE et 'c•Ookr CA-47)\ „W..% N.nek.i...4.,A -N."---c 4c-.0.-7.•--e_

COMMENTS: a4 cg.S. rh,-. .10 ey-, y---k-4-2 ,74 cs"---- '----\-°------ts

LATERAL: cA 4)"..k.a.„erl rr.r.,

■ LEFT SIDE UP p a...--...... cAkcs-Nr‘........_k

■ RIGHT SIDE UP c‘ew-% I. 14.4*"' , k 1

, trowied-v, olfur 14-e a 1-,./ 4,--....4t.e_cs-..S.

8. .SKIN PREPARATION

HAIR REMOVAL CS.. YES ❑ NO

DONE BY: 0 OR

METHOD: ❑ DEPILATORY

COMMENTS: ."ek.er A./...c,k_s il,c - Ce••..A-s,

■ [8

■ CLIP

NURSING UNIT RAZOR

.4-A.. A,

PREP OLUTION (Specify) g jacrk \Q LACN_ SIT 1,, BY WHO SITE.(9.sy,slykau Ao yrteN,943 Y WHO

COMMENTS: ..1,,v0 \I ,D 0.4.- Oct", A. l 4.004.4%1 vet) 9. LOCATION OF EXTERNAL

PP Old

DEVICES Of rtl

_ AA01151011,-..x.fg- "Is

TIIIVAPP

Cs.„71-(.0%

_ .

- "- ■ .i iimNislik__

LEGEND X Ground Rad WA — Safety Strap C,044. === Tourniquet __ ...

6.c.-P-CA ipi .

10.COUNTS


0 First Closing Count

Final Closing Count SCRUB CIRC .t • : (e.)--2-

Sponge N. Yes III No Needle Sharp f Yes ■ No Instrument • Yes No

C MO 1111111

Other ❑ Yes No I \I 11. PATIENT IDENTIFICATION (For typed or written entries give: Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

., \ ( (.0 ) r-- 1 C-.=

4

CW .2.,

Vgali44

12. ELECTROSURGERY DEVICES) (ESU) IM YES ■ NO ...._,

it EX ESU NO: Al 1.-- 'A- 6-4 01— it 4- ‘ 1'2 GROUND PAD: BRAND V (...- Ftk‘AlfteS;ve. It

30(30 LOT NO: ‘ 8°136 -2- 005-- 03 ■ ESU NO:

GROUND PAD: BRAND LOT NO:

❑ BIPOLAR NO:

-I , REPLACES DA encu "" • " "A"'.'M IS OBSOLETE. USAPA V1.01

MEDCOM — 15894

DOD-029283 ACLU-RDI 1634 p.54

13. PROSTHESIS, IMPLANTS YES EN NO IF YES NAME: ID NUMBER; MANUFACTURER

s414 . INSESEIRMIONESIEMERIIIM MEDICATIMMRDERVEHMISMEM006.13.renga! '.j IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES 0 NO ' MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

1

$ ii

:WOUND IRRIGATION lie VS III NO, TYPE(S):

1 ,, A 0 / 4 • 1 v-n le NQ.-CQ., OTHER ORDERS TIME CARRIED OUT BY .,,

• .. •.

.PHYSICIAN'S SIGNATURE

15. X-RAY IN OPERATING ROOM IF YES, SITE

YES LI NO 2 16. LABORATORY SPECIMENS

SPECIMEN (S)

YES • NO

NAME NAME

FROZEN SECTION (FS

YES LI NO

NAME

• NAME

CULTURE (C)

YES • NO

NAME NAME' •

NAME NAME NAME

NAME NAME - . - , 18. DRESSING/IMMOBILIZATION (SMcifY)

(.ft- acsmAlit) )

ANNic larVi ri%Lck5

14.9-4 X

---="1514C2-411/41k.......-k_eba _-t4

17. TUBES, DRAINS/PACKING YES rig NO • TYPE/SIZE 1.

2 -C Nati_oi 2. 1 kw Veiwym,

3.

SITE 1. --4,-...4.t. A‘poto-fv,,,....k

2. P lek•V••e-Q--

3.

1191.cAIT L INFORMATION

Surgeons Anesthesia: Anesthesia Type:

h 30 (30

Bovie Pad site intact pre-op 1/ ; post-op Bovie Settings: Coag/Cut Tourniquet Site intact pre-op 4.7 : post-op ,/ I, Tourniquet Time: Up I OT‘Down.114 i

20. OPERATION(S) PERFORMED

C• (--- i L".&•"'Nek- if•.•■ 1 il-QN°JZ- '63 \ Cx-C--A- A- I 19\c‘ rl'Y'r t3.81 1(11-

21. PATIENT PATIENT TRANSFERRED TO TIME WI- METtIOD A\--\&1i 6 &c,k,11 Ap f ox,

22. REGISTEEtED UR

USAPA VI.

C - E

MEDCOM - 15895

DOD-029284

ACLU-RDI 1634 p.55

/ ', . INTRAOPERA' OCUMENT

MEDICAL RECORD ) For use of this fonn, see AR 40-66, the propoi, ;fig is thAffice of The Surgeon General.

1. PATIENT TRANSPORTED TO OPERATING ROOM

VIA /14 BY 12../1acd../aval..4.

2. PATIEN ENTIFIED RECORD D ROCEDU E

VERIFIED .

3. D TIME PATIENT ARRIVED IN SUITE

kitc03..._.---

.... 5. PREOPERATIVE

4. PATIENT I

TIME 0 & NUMBER C -1 (2.....1_ EMOTIONAL STATUS

V. CALM ■ ANXIOUS ❑ EXCITED • CRYING • ANGRY ❑ WITHDRAWN ■ OTHER (Specify)

COMMENTS: Allergies: NK- b-ik


ASSIGNED SCRUB

0) --1-- RELIEF SCRUB

ASSIGNED . CIRCULATOR

err

66'-r

RELIEF

7. POSITION AND POSITIONAL AID

4SUPINE ■ LITHOTOMY ■ PRONE ■ KRASKE LATERAL: ■ LEFT SIDE UP ■ RIGHT SIDE UP

COMMENTS:

8. SKIN PREPARATION \

HAIR REMOVAL DONE BY: METHOD:

COMMENTS:

■ ❑

I

YES ✓ t NO

OR ■ NURSING UNIT

DEPILATORY ■ RAZOR

. CLIP

PREP SOLUTION (Specify) &)-Iki SITE° BY HOM.

..42-k24)/C.P 7- SITE: BY WHOM: t...

■ . 1-70/J

COMMENTS: IA•0 1....-642.4-i al) piLt.e..40 t.--eri-c4 _____.------


•

ti. .. - P .i 1 •

* LEGEND

_ --... ......- i-- .1110-

_... flaw.

, i Plati•d• 1" DS • 7 nd Pad a Strap === Toumique — 1 Mt A.% (;) 200 TA

10. COUNTS

Sponge Needle Sharp

C =corrIct I = Incorrect

3 Yes • No

Yes ❑ No

Int-t-A4 Other"

(1. C....,

First Closing Count.

Final Closing Count

Q- CI'

10 b-- .Z. SCRUB

-Stie

CIR ULATO .

Instrument ■ Yes No 1

Other III Yes No I 11. PATIENT IDENTIFICATION (For typed or written entries give: Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

-LA C ) V WV ( ()-

sz ESU NO:

12. ELECTROSURGERY DEVICE(S) (ESU) .a

YES ■ NO

Ut 7 -0 iici-G .3 se' - GROUND PAD: B D 0 a 0._-F77.c5-63-

LOT NO: a —0=5 • ESU NO:

GROUND PAD: BRAND

LOT NO:

❑ BIPOLAR NO:

......_......_ DA FORM 5179-1, OCT 87

REPLACES D

MEDCOM - 15896 i IS OBSOLETE.

DOD-029285 ACLU-RDI 1634 p.56

13. PROSTHESIS, IMPLANTS ❑ YES CT NO IF YES NAME: ID NUMBER; MANUFACTURER

. MISMINMMONNONNO:1.:i:k ;:,;1:018M MEDICATIONS/ORDEROMIW.M.MWOMMONter 4,:e.t.;:0,; IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES. NO

NEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

MOUND IRRIGATION

4

YES

M0

❑ NO, IdYPE(S):

IA A/1- .OTHER ORDERS TIME CARRIED OUT BY

yi

?PHYSICIAN'S SIGNATU

,...........,.....„..„,...— ..... .....,.....„ .-„,.......,. , ., .. , , 15. X-RAY IN OPE IF YES, SITE

YES ❑ NO


YES ❑ NO

NAME NAME

FROZEN SECTION (FS

YES ■ NO

NAME NAME

CULTURE (C)

YES • NO

NAME NAME

NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION,(Specify)

17. TUBES, DRAINS/PACKING YES NO ■ ei4"0-4

-7--Ato tpraid

TYPE/SIZE 1. t 1 2. 3.

SITE 1gfra, 0--pee..._, 2 . 3.

19. ADDITIONAL INFORMATION ' WC , Surgeons:1*W* Anesthesia:id% kr AnestheSia Type: Ge_,/, v...3 (a) - 2.

y6.c)

iBovie Pad site intact pre-op C' ; post-op CC" Bovie Settings: Coag/Cut ' 30'14° 30- tir() i


i 1

21. PATIENT TRANSFERRED TO ( at z... TIME

0 3- 1 0 METHOD

_

22. -1-0 REVER

USAPA V1.01

DOD-029286 ACLU-RDI 1634 p.57

MEDICAL RECORD ) INTRAOPERI ' DOCUMENT

'.3 For use of this form, see AR 40-66, the prop,. .. ency is the office of The Surgeon General. 1. PATIENT TRANSPORTED TO OPERATING ROOM VIA n vut, hz Ad BY 0.4V2,04-4.124.....za_,

2. PATIENT ID ED AND PROCEDURE VERIFIED BY Mrjki

3. D TIME PATIENT ARRIVED IN SUITE

ci- Ait 6 / 4. PATIENT IN

, TIME 0 3 / NUMBER b--/ 1 i )

/ i c .3 5. PREOPERATIVE EMOTIONAL STATUS i

U CALM ■ ANXIOUS ■ EXCITED U CRYING ❑ ANGRY i ❑ WITHDRAWN ■ OTHER (Specify)

COMMENTS: Allergies: (104..tds I


ASSIGNED SCRUB

Fra a l b RELIEF SCRUB

ASSIGNED CIRCULATOR

CP r 1111111}0 RELIEF CIRCULATOR

Cr Or (Pc7 OS--- Or7 o_.)

7. POSITION AND POSITIONAL AIDS (Specify) •

Ng SUPINE ■ LITHOTOMY ■ PRONE • KRASKE LATERAL: . ■ LEFT SIDE UP • RIGHT SIDE UP

COMMENTS:

8. SKIN PREPARATION '

HAIR REMOVAL ■ YES IX NO

DONE BY: 11 OR • NURSING UNIT

METHOD: • DEPILATORY ■ RAZOR ■ CLIP

COMMENTS:

9. LOCATION OF EXTERNAL DEVICES if.A.24, ..,

PREP • LUTION (Specify) Aey-e.../OM: Cl.pr

ilt/-4..., rib SI B WH SITE: v BY WHOM: -_______

COMMENTS: ,NA) p49.0-6-04_5 63 ...4.e.d ,

I. — ? i _ .11i- . ...., -_......1.......... .- . _ ........--- . 111- IP'—

1( la—tet. LEGEND aill Pad Strap = - Tourniquet v .0

10. COUNTS

Sponge II Yes ■ No

C = Correct I = Incorrect igitterg C.

asutn. losIng ionuanl rosing

C- Ci

V., IC) SCRUB ✓

9 Fe_ f Fc,

CIRCU .1. • :

a.. Needle Sharp 11 Yes El No Instrument ■ - E • ,

Other ...1:=12LesO No 11. PATIENT IDENTIFICATION (For typed Name - Last, first, middle; Grade; Date; Hospital

or written entries give: or Medical Facility;)

12. ELECTROSURGERY DEVICE(S) ULT.. — (ESU) •

0.-0 A- YES _ 111 NO

6

OA V 11111111,V LO- "I\

11.111.110 \I-) 11 1/ !1. r ........

fZ ESU NO: V al- 7s-r:,- t, 44-- a-i 4 GROUND PAD: B D i i ..:,. /.1.4

LOT NO: 10 : " 1111111111VP S. . ❑ ESU NO:

GROUND PAD: BRAND

LOT NO: • BIPOLAR NO:

ES DA MEDCOM - 15898

IS OBSOLETE. USAPA V1.01

DOD-029287 ACLU-RDI 1634 p.58

13. PROSTHESIS, IMPLANTS ❑ YES p&NO IF YES NAME: ID NUMBER; MANUFACTURER

p 4. !;;RingSSIONCROMEMSORIMSSON MEDI CATIONS/ORDERMEMOM IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)

VORMESIOMMONAIM: NO 7 YES •

*EDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

:y OUND IRRIGATION [^ YES ni NO, TYPE(S):

PTHER ORDERS TIME CARRIED OUT BY

THYSICIANS SIGNATOR " 1 CA j -- ;?.......,,,,.,..„.......,..,...,..w..,,,,.,..,

15. X-RAY IN OPERAT IF YES, SITE NO N) YES ■


NO NAME NAME

YES ■ FROZEN SECTION (F

NO NAME NAME

YES ■ CULTURE (C)

NO NAME NAME .

YES • NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)

,••• two p..svct

17. TUBES, DRAINS/PACKING YES ❑ NO TYPE/SIZE 1. 2. 3.

SITE 1. 2. 3.

19. ADDITIONAL INFORMATION WC ( 0- S ---2— Surgeons: Dog Anesthesia: 0-)er lei - Anesthesia Type:

Bovie Pad site intact pre-op; post-op. Bovie Settings: Coag/Cut &frr-ZI

• ,


T D 0 IfiKiLee_,

21. PATIENT TRANSFERRED TO TIME METHOD

22. REMIIIIIIIIiRE . CPT 4 GGe

REVERS FORM 5177 , CT 87

USAPA VI.01

MEDCOM - 15899

DOD-029288

ACLU-RDI 1634 p.59

MEDICAL INTRAOPERATI—TOL :NT L Ct ) -- -1_ ; 7...T use of this form, see AR 40-66, the proponent agency is .1.... office of The Surgeon General.

RECORD -./ .._ .

--,,,%, i ‘ For

1. PATIENT TRANSPORTED TO OPERATI ¢R :OM VIA BY Payika,atee

2. PATIENT IDE VERIFIED BY

OCUIUREfrej CPT-

NUMBER - 1 / 7.,) 3. DA

Au 61- TIME PA VENT ARRIVED IN SUITE

. 4. PATIENT IN TIME / -319

EMOTIONAL STATUS 5. PREOPERATIVE

fiLCALM

COMMENTS: Allergies:

❑ OTHER (Specify) ■ ANXIOUS ■ EXCITED III CRYING ■ ANGRY • WITHDRAWN

ift/ arA


ASSIGNED SCRUB

-C--"G RELIEF SCRUB

ASSIGNED CIRCULATOR

6 ' RELIEF CIRCULATOR

I S'00-) 3 ._

7. POSITION AND POSITIONAL

SUPINE

COMMENTS:

AIDS (Specify) 64.....eoai ay, , r,--,...,_, pukete et air 4.— /—eetA, ❑ KRASKE LATERAL:' ❑ LEFT SIDE UP ❑ RIGHT SIDE UP

10 ( 63 - Z-

< 6. M LITHOTOMY ■ PRONE

HAIR REMOVAL DONE BY: METHOD:

COMMENTS:

YES W_NO OR ❑ NURSING DEPILATORY El RAZOR CLIP

8. SKIN PREPARATION

UNIT PRE - ilk TION (Specify) SIT: BY SITE7111Wir

HO • 4 . eff

WHOM: 1

/ ,I

C:ii /°t‘P.19 '

BY

■ ■ •

COMMENTS: 1A-0

-

■


,.,

3,... r 0

• AlIWIPIftmt.1%.;

, --.------

Vu)- ,y, === dirn

Kiquet

- I

LLEGEND

-.maw -41:4- .......- TIICAPP--

- --..--------

-

( 0 - 2 )()ei •--Ar .ef

10. COUNTS

r orrect ', -Incorrect I h t First Closing Other** Count

Yes ■ No IMIIIMMIEMIl ir

Final Closing Count SCRUB '

1 ME

11111115:11111

CIRCU • TOR

„Wail Sponge Needle Sharp Instrument

I I Yes II' No gatilIMININIMERWM ■

Yes No __mow Other ■ Yes No 11. PATIENT IDENTIFICATION (For typed or written entries give: Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

fp pli Mb ■ CSt\) -1; •.

111111111111116 \O (. 1) - 1---

12. ELECTROSURGERY DEVICE(S)

❑ ESU NO:

(ESU) • YES NO

GROUND PAD:

• ESU NO:

--. BRAND VatAi a_i e-a -o LOT NO: terq 240S-o3

GROUND PAD:

❑ BIPOLAR NO:

BRAND LOT NO:

PLACES I MEDCOM - 15900 :1-1 IS OBSOLETE. USAPA V1.01

DOD-029289

ACLU-RDI 1634 p.60

13. PROSTHESIS, IMPLANTS 0 YES \NO IF YES NAME: ID NUMBER; MANUFACTURER

Igainnagliggiginni:gaggigfiginNE:NONA::: ME DICATI ONS/ORDERSNMERNMEM IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)

YES Q1. NO

MEDICATIONS/SOLUTION DOSAGE TME JIETHOD PREPARED BY GI 4 - 1/1 ! it■ i -.I 4 I . 10 / , / P ,

i 1

1

MOUND IRRIGATION IX YES ' fl NO, TYPES):

1 ,,

:, OTHER ORDERS TIME CARRIED OUT BY t • 3 ti

11 . ..■ •i.

PHYSICIAN'S SIGNATURE to(u)-- Pt_

15. X-RAY IN OPERATING 0 IF YES, SITE

YES • NO 16. 1 LABORATORY SPECIMENS

SPECIMEN (S)

YES • NOUIJ

NAME NAME

FROZEN SECTION (FSI

YES El NO

NAME NAME •

7 i- 4:P- 7 CULTURE (C)

YES • NOEl

NAME N ill

NAME

NAME NAME NAME

NAME NAME

17. TUBES, DRAT Dt4SIPACKING YES 6 NO •

•-- c&_,

18. DRESSING/IMMOBILIZATION (Specify)

1,0,CLy9

TYPE/SIZE 1.j9? ,e,hroe.

2. 3.

SITE lap 2. 3.

19. ADDITIONAL INFQRMATION WC

vp V 666;4.

Surgeons Anesthesia: j sthesia Type:

Bovie Pad site intact pre-o ;it- post- ovie Settings: Coag/Cut 31)/3 () :fif


1. ...Tr. b 21. PATIENT TRANSFERRED TO

(_(),,, ri. TIME ,-- //

METHOD .

1 4.31-- .A.-4.)

FORM ,

- USAPA V1.01

MEDCOM - 15901

DOD-029290 ACLU-RDI 1634 p.61

.2) MEDCOM - 15902

t2 P , 1.1

LVtic° - z CI MI

TO

TA

L

i, -1

0

WZC 0 -1

x z m

TOTA

L ge.01-0" ce.. O

UT

PU

T ..—

..._

0 -I .§Z,71:1— - 0 -1,

c 1,3 0 IV

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301 Ai -17-9 g

Y.. Vel 5211E1 . r

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rZAI

Imm" C

4..., El 0 W fla

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1111

rii 1 9 6 a Firin.' VA

P ...g7; §

'

119

W a icr,iit Liii

3 .6. 11 * L-1 3

9 5 8, cal Ilb IF;;4 e Et P E :i. . ̀t9 r o 1§ 0 1 g

DOD-029291

ACLU-RDI 1634 p.62

- 1 c x z 0

W. -i 0 -I

Z > r

m

0 zcO -I - 40 wa O -4 z -i -4 O m 11 ✓ a r

.-1

Z "V

▪

CA XI I -I CO 0Z 0 -a 0>MXIM

• -

0 - I C tv 2 11 -I

1111P111111111111111111111111111111 1113111111111111111121111111111 11101111111111111111111113111113 111111111211111:111111111111111 11111 1111111111111111121111111111 111111111112111111111E11111111151 11E111111061111111111111111331zEi 11141111111111111111111111111111 111111111111111111111 1111111111

11111011011111110111111 111 111111111111111111111111111161 11011111111111111111111,111111111N1 1111111111111111111111311113111IN 1111111111111111111111111111111211 11111111111131111111111111EMIN 11111111111111111111111131111

1111111111111011111111111 110111 3' 8 v) ,T k ,ftw,F.

ACLU-RDI 1634 p.63

511-119

N N 754

MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY

POST- DAY OR At.AC r)3 MONTH-YEAR DAY it• 4...

tESPIRATION t, e 17 0 . . 0

f

-a -c-.)

i

Ia. f_______9L__._tL±0)R

PULSE TEMP. F

180 .04°

170 103°

, . . 160 102°

150 101°

140 100°

130 99°

110 97°

80

60

50

40

RECORD BLOOD PRESSURE

0-a-Sak-

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REGISTER NO ' ",:;:r 4.

Y.+

DOD-029293 ACLU-RDI 1634 p.64

MEDICAL RECORD . VITAL SIGNS REG RD

BLOOD PRESSURE

. a

TEMP. C

40.6°

40.0°

39.4°

38.9 °

38.3°

37.8°

37.2° 37.0 °

36.7 °

36.1!

35.6 °

35.0°

0

C.,

Ell

cc 8

4— er; • c a)

ET

CU no

MEDCOM - 15905

HOSPITAL DAY

MONTH-YEAR

19

S HEIGHT: WEIGHT ••= ►

PULSE TEMP. F -(0) ( S )

105°

. =111.14,.. irrilM11. 17411: 110111E1111,M1 ''''' ilMEIMERM

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' ' .. INIEPPMEWEI FAWMMENTIMIraffilifilialir0

REIVIMMMWM NIMM.11.11111

1,M11111111 italaymolinlit:11:111 110113 Klaiillaiffill11111M111111•111•111•1111WINMI ■M= GTAmmramammumromismwes seimmi EMITMISTV J5b 1111111idilial

41I4

POST- DAY

DAY

HOUR

180 104°

• t ,

170

103°

160

102°

150 101°

140 100°

130

99° 98.6°

120

98°

110 97°

100 96°

90 950

80

70

60

50

40

RESPIRATION RECORD

73 s- 6. %ID

PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, fist, middle; ID No. REGISTER NO (SSN or other); hospital or medical facility) 17(.01_ -411

\r)

J

STANDARD FORM Sit (REV. 7-95) BACK

DOD-029294 ACLU-RDI 1634 p.65

99° 98.6°

98°

130

120

90 950 35.0°

80

HOSPITAL DAY

POST- tnfiF DAY

DAY 12- HOUR 2(7

PULSE TEMP. F (0) 1')

105°

180 104°

170 103°

160 102°

150 101°

140 100°

110 97°

100 96°

40.0°

•

35.6 °

TEMP. C

40.6°

39.4° ,oc

38.9 ° c8

a)92

38.3 ° 8

37.8 ° acn.

37.2° 37.0 °

36,7 ° CU

36.1 °

70

60

50

1. 1-.

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41-1 , 'Ili y5 ' isa

i -a, I-, A. a 41 g■ it ri r.e.i .Ori r'r.S- 0 p-_,

ad m_cY

VITAL SIGNS RECORDS

Medical Record

STANDARD FORM 511 (REV. 7-95) Prescribed by GSAPCMR, F1RMR (41 CFR) 291-9.20

0 ID

:PATIENrS IDENTIFICATION (For typed or written entries give: Name—last, Fist, middle; ID No. REGISTER NO (SSN or other); hospital or medical facility)

40

• I RESPIRATION RECORD

BLOOD PRESSURE

-,0 ,Y3•4 a $ HEIGHT: I WEIGHT .=.-101.

CV t26-A, evIS QZ 0(444

ly w

hen

so o

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ed

DOD-029295

ACLU-RDI 1634 p.66

MEDICAL RECORD VITAL SIGNS RECORD

HOSPITAL DAY

POST- DAY

MONTH-YEAR win DAY 19 i>9" rfb HOUR " '' • " • • • • • • • " • • • • ' " •

—

PULSE P. F (0) (.)

105°

180 104°

170 103°

160 102

150 101°

130 99°

98.6°

120 98°

110 97°

100 96°

90 95 °

80

' -

40

RESPIRATION RECORD

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• • •

. .

I • • • •

•

• ' •

.. 1... ..

1.0

• • • . . . . .

14f3 le# *

int,

3 on

•

. . I TS IDENTIFICATION (For typed or written entries give - Name—past, first, middle; ID No.. • - ' .r); hospital or medical facility) ••

.N or othe - . .... . .r . .. - .

REGISTER NO • WARD NO.

DOD-029296 ACLU-RDI 1634 p.67

-Ward/$gctj i -F Rai V.

34-5A (dl 26784

7047 uil

14797 mil

11-38 u/I

0.2-1.6 mild

7-22 mg/dl

8.0-10.3mgC . •

100-200'n/di

0.6-1.2 n44

73-11g:14d]

6'44.1 EVA:. '

! RE

RANGE 73-118 mg/di

7.22 mg/d1

0 6-1 2 g/d1

39-380 u/I (M 30-190u/1Q 128-145 m4to

2:

PICCOLO 11/08/03 03:47 REFERENCE RANGE: PATIENT #: METLYTE 8 DISC LOT #: 3152AA4 OPER #: 013 DR #: 000 SERIAL #: 0000100676

GLU 103 BUN 5* CRE 1.1 CK 314 NA+

K+ 4.0 CL- 96* tCO2 24

INST QC: OK Cl-EM QC: OK HEM 0 , LIP 0 ICT 0

138:1460:061/L

TR-

P02

TCO2

731-7.45

35-4.5 mmHg tart) 41-51 mmHg (yen) 80405 tronli0 (ert) N/A. veil _ 23-27 trimol/L (m) 24-29 mmoll (yen

s02 95-98% CHOL "

.1. I2-L32 mniollL

8-26 mg/dl •

1020minoliff.

0.7-1.5 mg/d1,

38-51% PCNrc

12-17 g/c11 .

73-118 MG/DL 7-22 MG/DL 0.6-1.2 MG/DL ' 39-380 U/L ' 128-145 MOW 3.3-4.7 MMOVL 98-108 MMOVL 18-33 MMOVL

;

98=1081: 01/

18.33 mmolfl

' ... aw

ICO2

1

LAB ID `REPORTED BYY" DATE: -

MEDCOM - 15908

DOD-029297

ACLU-RDI 1634 p.68

DOD-029298

Negative

Micro Parasites ,

Malaria

roscopie Urii

LABORATORY . RESULT FORM Suliect Zo the ac Act of 1974

SSN/P

0.2-1.0

Negative

-MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED

Cell COunt

Diredigen

!LAST, T.

4.8-10.8 x 10...1

4_7-6.1 x 10

14-18 Wdl (M) 12-16 a/di 4242% (M) 3747% (F• ' 80-9411(M) 81-99 fl (F) .

MGV7 _Negative - '

Negative

: : 130L590x10. verified

LYIlip711 20.5-51.1°6 ;

010/1:11611i0W101/14

SG .

B1d

PH

Prot

-Negative

D dimer

MEDCOM - 15909

DATE: LAB rcr NO.:. .

ACLU-RDI 1634 p.69

DOD-029299

G PHYSICIAN:

,•-!•!4..

fk r̂f: • LABORMDRY RESULT FORM`

1974;. : TIME r t :SSItT/PS.Dk SSN:

• •-• • Warri/Seepo

LAST, FIRST,M.

•

RESULT REF RANGE Col&

N/A

Negative

_ _Nega!!vc, ..„ -: _Source_..

.,: RI ;,ritt i.•:. irsun tt-: . % . qtkill t ' T §-Inv:. ,...A. ,,,. .-.,

N/A . ;q

! .(r OCTCid:

NegatiVe

N/A i01-111, Micro" Parasites._

Negative-

.Bili _

-Ket.

SG

!•,

egatiVe;

77:

'Lk&

7—

Sed Rate*:

Dircctigen sa•

REF.

9.8-13.6 secs

21-34 secs

0 = e71-7

!•.! ;

. .

Negatived

••ZregatiVe-a....-

• • - _ • -

<10 ug/mi

114— REPORTED BY: I DATE:—

MEDCOM - 15910

REMARKS: VAAA'

clgt.' r„,

•-•

ACLU-RDI 1634 p.70

<10 ughail

REMARKS:

LABORATORY RESULT FORM= Suliect to the Privacy Ackof 1974)

SSNIPSEUDO SSN'

REQUESTING PHYSICIAN 1 •

• '.112

" :.;

TEST RESULT REF. RANGE TEST RESULT REF. RANP4 . 2,:j •

15:57 PatiEnt LiTits

12,3 H x10':. _. 10.5 r,:EfC 4.36 x1 0"6/5i 4,00 6.00

12. q/fi; 11,0 Fct - 3,5.0 60,0 ?TN 54.5 11 N.0 99,9

P9 27,0 31.0 rEHC :0.01 gltiL •3.0 7.0 Pi 175. * x1P3/4i 150, 450.

In t

'% * x10'11/vi 1.7 3.4

REF. RANGE , 4.8-10.8x10':' '

4.7-6,1 x 109

14-18 (M) 1246 dl 42-52% (A+1) 37.47% (Fr' . 80-94.fl (M).___-. 81-99 fi (17)

130:500 x ice verified

20.5-51.1%

Color N/A

NIA

RPR'

Mono

ive

Negative 4i

Glii Negative Microbiol

Ket-

SG

Aj-

°if

_ _ Negative _

'N/A

Negative _ Source .m17 ,

Gram

cc-Bler

Bld N Negative,'

. • • •

• " • .•

N/A Micrd-Parasites

UrOb 0.2-1.0 -

Malaria

O. & P.- •;

-Baso - Other

C,144t: ,— '' '7..7:0 ... , .,,, I. • • s• 2 4 07 1 45•2 II ••• I

C11-'r PU-Cia : KY Al Wee.,:-..4 410-

-CSF

r . "4 MUSTSUBTVilt171.518- 8VITH': EVERY UNIT REQUESTED

9.8-13.6 secs

21-34 secs

<20 ug/rnl

PT rilafr.n

APTT

D dither

LAB IED NO.:.

MEDCOM - 15911

DOD-029300

ACLU-RDI 1634 p.71

04.01/1-. _,91/Lr•

bbU i-STAT 6+ •

! - Pt Name: HS m9. LtEq._. 1-15 (trt)

' - ----11---- Glu 126 mg/dL IL Cart)

AL Nr..0 BUN 5 mg/dL

Na 1Z7 mmol/L 4- (en)

K , 3.0 mmol/L -L.__ , i

Cl 106 mmol/L - i

Hct 30 '.PCV 0.4

flb* 10 g/dL tuipla., 4---2,

*via Hct i

Sample Type_:

99RUGOS 16:91

Oper: 7702

Physician:

Sen it 40763

Ver: JR145946R CLEW R93

NOE

1

.c.titAUSTRY RESULT KIRK sulica to the PTiv Act . of 19:74)

SSN/PSEUDO SSN:

srclA ' .

. _TEST ST _RESULT REE RritVGE . _7.ST 1ESULT: -. - .1.._ .REF. EiNds

GLU

3UN- •

plixtto 09/08/03 15 :

: r1ci IliKc ' . _ PATILN1 #: MLILX:E 2 DISC LOT p: 311*IhAl OPER #: 70? DR #: O CO2 SERIAL #: 00001002

GLU 132* 73-118 MG/DL BUN 5* 7-22 MG/DL CRE 0.7 0.6-1.2 M6/DL CK 559* 39-300 UA

tC0? 29 18-33 MMOVL

INSE QC: OK CHEM DC: OK HEM 0 , LIP 0 , ICT 0

'TEST

73-11810/dt;;T

. 7-22 TO/di • -.5"85;

8.0-10.3

0.6,1.2 mg/d1

128-145 mmolJl

3.3-4.7 gurno1/1

98-1011mmo1/1;;:4

18:33 knmo1/1 ; . f

■■••■•■••••■111■

3.3-5.5 'ea

26-94 utl

10-47

14-97 till

11-3810 • 02-1,6 mgli

5-65 WI

i 6.4-8.1 Wdl

, - 0-XlectFol

REF. RAIYOEI

ALB _

?..5.5. • • .1.

4 -. • .1

IILB

LIT

ILT

1ST

TEST - -RESULT ' REF. -RAINVE7'

RESULT

CO

128445 mmo1fkl

Abuse ,

V.

REMARKS: L :

cfr REPORTED -11Yr-

- DATE: LAB ID No.: d 3 _

MEDCOM - 15912

DOD-029301 ACLU-RDI 1634 p.72

Ward/Section: /2---

REQUEST} PHY ' ‘. . ,:. . (

LABORATORY RESULT FORM (Subject to The Privacy Act of 1974)

LAST, FIRS , i ' ...

-\\, Jr' 3 TIME

0 YO6 SSN/PSEUDO SSN;

- . :. - . • Urinalysis .:,. Misc. Serology t pr_cl/T.T I REF RANGE TEST RESULT REF. RANGE TEST RESULT REF- RANGE

b(' I..NN-1313-0 Color 1 1111111

1 a 04!7.15

N/A RPR Negative

Patiffer: App N/A Mono Negative

1 Li:fili75

..., 11,,, . ilL 4,2

Glu Negative . NntroblOktgy .•

Rik 4.23 x 1 0'6fuL 4,00 6„ CA)

4 j:isib 1217 gidi_ 11.0 18.0 Bili Negative Source

Rd; 39,7 ::: 35.0 60.0 Ket Negative Gram Stain

.

n 30.1 po 27.0 31.0 r[14.: 32.1L g:/di. 63.0 37.0

SG N/A Oce Bid Negative

L Pit 2:74. y10'3/!_d_ 150, 450, LJ/ 113 *L

Bid —..

Negative H. pylori Negative

1204 1.12 * x10'311.1L 1,2 :, 3.4 : pH N/A Micro Parasites

-

S Prot Negative Malaria '

B Urob 0.2-1.0 0 & P

Lymph Baso Nit Negative Other

Atyp Imm Leuk Negative :. roscoine Urini sii •

RBC Morph

HCG .

Negative

Spun Hematocrit_

42-52% (M) 37470/. (17)

- • Blood.Bank .

Sed Rate

, . Cell Count .:.

MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED

Other Directigen Negative '

ABO/Rh

' :.•:: ,- .i....CiiagulntionTStudies.: . -

-..:.:. .: .1:• : ,:::- :::.-:::,.... r' '2 • -..::: , ', .:.. i... s:.

.,:::•• .... : ., .... .B104Banit UNit c-iatisinitCh - ...'.'• '. ;

. (ThiStSUOMIT.Sf5 .18.WITOryuty uNfirOt.)00D.: " ... ,,: I..: :,..• • . : ::.• ..: :- . .,..REQUESTED) :, ....--.. -.... • • .7' :-.: ."' - ..-.:

TEST RESULT REF. RANGE UNIT TYPE CROSSHATCH

PT 9,8-13.6 secs - -

/PTT 21 -34 secs •

D dimer . <-20 ug/m1 -

FDP <10 ng/m1 •

- REMARKS: .

REPORTED BY: VATE: 23

LAB ID NO.:, .. . . . •

MEDCOM - 15913

DOD-029302

ACLU-RDI 1634 p.73

TEST —REsur BEERCV 3Z5N

Na ; — 1381463pli ii,

;,&7.1., TIT:5-4.910y1.1

–

H VV-

PCO2 35-45 mmHg 741:51Inttili8 tifei 30-105 ttibillig Ki! 1.1/A(veaT.SM

TCO2 niUL (si

24-2.9 ugmefiL(1.4 ----• –22'-7.;.640:001;;Sai

V .

2.3.0iiiatATA

s02

BEecf

AnCrap i0,20,333106.,1.

Ca 1.12-1.32 amp!

BUN .8-26 mecll

GLU • - -4 '70405 mg/d[

JJT RF4T,R4- 13 kr '4

------- PICCOLO ------- 07108/03 04:37 REFERENCE R . MALE

PATIENT #: 10;)- GENERAL CHEMISTRY 12 DISC LOT #: 3142AA4 OPER #: 678 DR #: 000 SERIAL #: 0000100494

ALB 3.1* 3.3-5.5 6/DL Vt0 ALP

59 26-84 U/L

ALT

54* 10-47 U/L

AMY

34 14-97 U/L

AST

58* 11-38 U/L TBIL 1.4

0.2-1.6 MG/DL BUN *** 7-22 MG/DL CA++ 9.2 8.0-10.3 MG/DL CHOL 140 100-200 MG/DL CRE 0.9 0.6- 1.2 MG/DL GLU 97 73-118 MG/DL TP

6.7

6.4-8.1 G/DL

HEM 0 LIP 0 ICT 0

T

gos))1\

\\;

Pt

Pt Name:

M9/dL

:110/dL

Ha 141 mmol/L

K 3.6 mmol/L

Cl 106 mmol/L

TCO2 29 mmol/L

AnGap 10 mmol/L

Hct 37 .PCV

rtb* 13 9/dL

*via Hct

pH 7.419

PCO2 43.3 mmHg

HCO3 28 mmol/L

BEecf 4 mmol/L

Sample Type_:

07RUG03

0Per:11111

Physician:

Ser# 40763

Ver: JAW5046A CLEW A93

15.4.4 .M. :104 1

REQUESTING Fkini

P022

•

Creat

12-17 INST QC: OK CHEM QC: OK

.C1:11111STRY RESUIT,FORIVI, (SuVect to the Privacy Actbf ,104)'

A„,461=5510. • _TAW IWT1' Ak,Wg_

CT Glu

BUN 11

Ward/Section:

/4

_Sectio :

1•

. _

5-; . i CC-, 1D. ',-.1-7.1, LAST; FIRST, Mli‘g g • • •• •

•:-.r. CX"' .. , ,.:

0.7-1.5 medl

38-51% PCV

- Dfug-61- Abuse .

SSN/PSEUDO r

BU 4iTRT EC8+

CR NA

Al

Al

I-TEST r?..'

REMARKS:

-tv REPORTEDItYr

kill 4 . '4',

Hct

BO)

•- • _ • • _ - •

MEDCOM - 15914

DOD-029303

ACLU-RDI 1634 p.74

Ward/Section: ,.Zii ..-.-•:.-:

Rgq.qP, 4 ,

' :, • ' • , • 7 ; cHEMISTRY.RESULT. FORM_

•: ' '' '{Siitilect to the Privacy Adcel4974)' 4V, I

LAST, FIRST, MI; .-z '1 . _ _ c‘.., <.:: .'. , 1e..4

, ---, ..'

it ... , ; .

=., ,

PATE 0

c." ' ,,,.... . .

TIME • ■ -0 •

'S$11113SE •; .

11

...:iiti7.f. . • .'--.157:.

4-4 J C. .•,?•••, :l.,L';•■•,•i;:...z:i;Y: •!•• ..'..,:,,..-••,;? • 4 '2 22;-, ,' , .,;:, !•;: ' , ' V ::.;•••• - - .

!.I.•.-1-: ...,,,. : • • 1 I , ' ,,i6iic.2.7. 1-1‘..1.- .I'•'; • ' "..s;!•1 I

TEST ' . ...,

REStILT • i .:,.. _. .--.?.

REF. RANGE : •• .,- ..-: ::

TEST _ . ..';-.. -.

RESULT : --. • .2

REF. ...; TEST .21; 1VINCE , .-.) .‘1 . .I• ''' '

_REquLT . . 7•., . . '2 '

- jt,E.,f, B.Alia6, ' .AS I T";.„:.;.- ','

Na ":",:::. 7 • — '138-1467311:R4i1-: ALB 15;55e-d1. . r . GLU,S -;i:: ,, , , -731118 arg/tir;..r

g.- 3 5-4 9 ramol/L: ALP •----26714-a/1.4 1 .., i BUtsi , . 7-22 mg/dt - .-

C1'•- "• - . 77' , -----. r: ' -.9 --,-...:-.1 . •I

ann1/1: • 9810 o

ALT :w.,, ,..., -4-' ... . 10470 - CA+ - ) • : .••• , . ----1`. ' -;.! 8.0-103 nigidl .

. ., pH .... . - .. - —....7J177,..45,...„„z .- , -AMY- -. - 1497 ,...... .cRE , ::: ... : t ...., 11 .3"

- -.-'_. _

' ,... 0,6,423w/d1

PCO2 35-45 rimiHg (art) 4151 aunlijtOe10 - -

AST - - - - - s •

t t....38 u/1 NA !'l ,0.-r ! --

,- 128-145 mir+01/1

P02 8°-105 zninlit!)(afa) WA (veil, i- 1 - ,

TBIL 0.2-16 44 , K+ . 0. • 33-4 ',7 rafoo14

TCO2 ' 23-21A1?191.11:.(811) .24-29 minol/L (Yen)

BUN 7-22 n;igldtf CL7, ; • •• • 98-tos mm01/1 •4 ,7, ,

-HCO3 • 2240710*13410) " 2348 inilieUL (In)

CA :' . 8.0-10.3aWdr ICCii: --- - - 1

• ••(_ .. ...1: ,..Littot,1

s02 95-98% . . CHOL 100.200 ingkil •PICI, )141vOr . _ 11, „ . ' ' ,l. ' ,

- BEecf - (-2) ---:(-1-.,--: ..- 'mrail/L. ;‘..'

CRE

0.6-1 -2 ingta- —TEST- - ,',.-.,•-; i

-RESULT- 1) - REFr-RAINTGE. ,!7

i ...4",......:: .: i

•' -AstGap - -- - '10.20;Foino1/1 GLU ....: ',. 73-118 Rya ALB -

Ca _ ......._ _. i .12-1.32 nimol/L _... . .

TP

6.4-8.1 gicil _;, ALP .. , .,.

26-84u#1 •

BUN 8-26 Mid! ,

' . t 7 00 e '. ' T ; .-..:.-- , l'i,,. —

10.47 to

_ ...____ . .

OLT -' - - 70-i 05 mgtd1 '.. TEST - RESULT -

:REF. : AMY RAXQ.E - - --- ----

,. 14-97 *1

- - - •

Creat 03-1 -5 Inficli GLU 73-118 mg/d1 AST • 1) -38 un

Het 38-51% PCV BUN 7.22 airgl .. TBIL 0.21.6 mg/dt - I

Bgb 12-17 g/di CRE 0_6-1.2 mg/d1 GOT • . 5-65 ttil

, - •••• .....-: •:• .1 -4.' CK ic-i 39-380 a/1 04) TP••• ''': - -

30-190 uA (F) ' 6.431 01

klEST .,' •ZT4.5E-AT:: ... 8.6F,' .RANGE NAf

. ‘,1,. , ,'

:' '. -., A, •

..:

'

1211-145.mmolil

::nui.:. 1 t. •

-3i41. 1timolit '

'•-,F 7.

TEST

4ccoo kEICOtr.

RESULT

obc ,....-; . -4.•

REF RANGE, ..-,-....:: Troponin-1 - - ' ' ' '1, f,:: •.• 7:: ;

•-, .!- ',., 1 7 77,PU . '; —7-.' — — ' 98-108 za.mo1/1 -

:.

-14A/ . ..,-: -73, --::: -- , •:. 128.. ,14,5,mmol/t...,...-. .

r 2 18-33 mmolll ,

K4 33-4.7 mmo1/1 - - - - -- , .,.„_ . ....

,•:- " .

- - -- - tCO2 1.8r.3. 3 _ffilau411 .

REMARKS :

• Ni)-V\I .A., • •

REPORT 1 --- - - - ----- ;

DATE: .-- - ,LARID.NO.:--

.. . . ,

.-- .... .. . . ... ...,..-: • —

. `,. 7 , " : , ^ I • 1', i ...; 17.( "_:

MEDCOM - 15915

kA

DOD-029304

ACLU-RDI 1634 p.75

Se

Ve l

[ADORN' , _. /RESULTS FORM (Subject to Privacy Act of 1974)

LAST, FIRS .

eTi/t)

STATUS RANK SSN

Time cal ed C ed to Physician -----

Date

- --N •Chemistry (Piccolo Analyzer) ClIen...._zitcgolr':.

TEST RESULT REF. RANGE TEST RESULT \tEF: RANciE

N'',- ALT 10-47 U/L

1 -STAT ECA...^r AST 11-38 U/L 1 \•

..)---

- c/

P:111111111/ --: 01 ._.

ML Lik

41K 2.0 * x10'3/ 4.5 101,5 RBC 3.66 L xl0A6/81 4.00 6.ek HO 2 ' 10.4 L 8/L 11,0 .0

, R...t 34.6 L 7. - "S5.0 63.0 itti, 94.6 tL 80.0 99.9 T4 M.4 n ri.o 31.0 roc 30.0 1 gidL 33.0 37.0 Fit 259. 110'3AL 150. 450. La 10.1 *L 7. 20.5 51.1 UN 0.2 4,1.' xik,31=4 L2 3.4

. ....

t : iillet GGT 5-56 U/L

pt Name: ALB 3.3-5.5 g/d1

) ALP 26-84 U/L I 1 U 161 mg/dL . )

Amylase 14-97 U/L 1UN 15 mg/dL ) la 139 solo lit a) Ca 8-10.3 mg/d1

ri) $.8 mmol/L 110

Chol <200 mg/d1

Amo 109 Amo 1 ./L Creat 0.6-1.2 mg/di -

co2. 28 Imol/L., . . ., .

BUN 7-22 mg/d! nGap 8 IIIPI01./L ' ..---. . • ct - •

GLU 73-118 mg/d1 37 %any

47-...--..-- ' . ' - 13 9/..d/: Tbili 0.2-1.6 mg/d1

.• .,• 4t.)i a Hct ... TP 6.4-8.1 g/dl

... ' -• 7.515 UA 2.2-6.6 mg/di (F) 3.6-8.0 .: dl M

'OE • 32.9 mmHg

-,

Urinalys ta3 27 MMOI/L ficfc:- - •

TEST RESULT REF. RANGE 4 amol-/L

Glue Negative

!vie tyjirtr4;-:, Bili Negative

1RUG03 14.-'$'x•14.-'$'x• '-isk . . . .

Ketone •

Negative Spun Crit 42-52% (M) 37-47% (F)

• ';I ' arch err. • . • • ••••.-

SG N/A ManAriliW 4.8-)0.8x to' •

vsicii0 --. Blood Negative }fit 130-500x 103

verified

--■., pH N/A Microbiology -# 49763 .:.: .

^: JR115046.A\Z ' - Protein Negative Source

CLEW 4493 '..., Urob 0.2 - 1.0 Gram Stain

., Nitrite Negative Culture

i..... I

. _. Leuk Negative KOH/WP

Trilfrerd Microscopic O&P

DOA Occ Bld I Malaria 1

AMTVler hCG Negative Other

OTHER:

MEDCOM - 15916

DOD-029305

ACLU-RDI 1634 p.76

1413 ORATORY It ES ULT. FORA Sub'ect to the Priva c Act of 1974 SW/PSEUDO SSN:

MEDCOM - 15917

DOD-029306

ACLU-RDI 1634 p.77

33.4.7 mmolit.

14:35 MALE

Rt 37C PH-- ---- 7.447

-mmHg39.9 mmHg PCO2 ----- _ PO2-------- _76 m09

HCO3-------- 25 mmel/L

Mee ----- --- mmol/L

02* _____ __ 9G %

*calculated

5ample Typa_r.

OGRUG03 14%40

Oper% 0

Seri 42011 "# Ver' JR14040 CLEO R93 ------------------------

PI 0

•

6/08/03 REFERENCE R PATIENT #:

5-98% OPER #: 269 DR #: 000

oUL lve METLYTE 8 DISC LOT #: 3141AA4

SERIAL it: 0000100676 --------------------------

/OtarMUL OLU 103 73-118 MG/DL

W 7-22 MG/OL

32.1 1°'! Du%

0.6-1.2 MO/OL CRE 0.9 CK 2449* 39-380 U/L -26 ing/d1

alo5mol NA+ 122* 128-145 MMOVL K+

4.3 3.3-4.7 MMOVL CL- 103 98-108 MMOVL tCO2 25 18-33

MMOVL 8-51°/ PCV

2-11 INST OC: OK

CHEM OC: OK

HEM 0 , LIP 0 , ICT 0

RANG

s02

-.7.=7. PICCUJ3 7-.7.--------.

06106/0 4:50

MACE

PAI 1011 #:

LIVER P, -t PLO'S 3135BA4 DISC LOT it: OR it: 000

SCRIAL tr. 0000100681

-------------------------- ALB 3.4 3.3-1a.5 G/OL ALP 60 26-94 U/L

ALT 444 10-47

U/L

AMY 29 14-

U/L

AST 72* 11-.6 M6/0L

38 L

TBIL 1.8% 0.2-1

, 6GI 13 5-65

U/L

IP 6.9 6.4-8.1

G/OU

OC: OK CHEM OC: OK

INSI HEO 1+, LIP 0 , ICI 0

1

- - ------

1-;51RII-G3+,6/

Pt% 00 Pk Mame: -----------

-- ICOZ__ ------

MEDCOM -15918

DOD-029307 ACLU-RDI 1634 p.78

DOD-029308

t o

AIR L/Min N20 02

L/Min

L/Min

' (

IMIMIIIMIMEIM2171M1 '11K

IMINtri-ou 1•111111111.mil

BP/Auto Cuff BP/oth

ART line

fr-Prvh.a..1■1•Pa. IMIAZINA

NISMI21111111111ffialidLiff1:411 MIN

1111111011011111MIBINI 71/11111,7A F/FA

SINGLE DOSE DRUGS-MARK ON GRID WITH NUMBERS & ENTER IN REMARKS

UNE site ❑ Warmed

❑ Warmed

❑ Warmed ❑ Warmed

EST BLOOD LOSS

UR NE -

BP by cuff

V

A Heart rate

• Reap rate

BLOOD-

CRYSTALLOID-

r° COLLOID

0.5

Code drugs with numbers, events with tattlers

ewe r 10,

Ztirro ce-244fiat eg20

Oa, 08.4,s-tr4-5

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..1- T

TOURNIQUET

T

ANES- x-x PROC-8_0

f - breaths/min Peak Inf pros / PEEP

0134 gfr 70 6-6r GSS

MODE - S('on) Alssist), C(on)

Specify) PACU ICU

Steth- PC/ES

Gas analyzer

OTHER

CONDITION:

RESP- sS Sp02-

la

Cony warmer

Mark with letters & symbols, , f explain under REMARKS Position

PROCEDURES and CPT C es:

PATIENT IDENTIFICATIO : Typed or written entries: Name, Grade/Rate, Medical facility

Alp

u Ready Begin End

: Intubation route, blade, tsc..hnique, comments 6114147t4 • 5rtt/ inifre [14'f 7/...rec fr c".1 COT ,Arit-

V .Y\) -1S,-

AIRWAY MANAGEMEN

athell

ANESTHETIC TECHNIQUES: Describe block technique under Remarks Lima

MEDCOM - WI /1/49 11//,‘ i Alf,” A v.

:AGEI

OK?- Y

#41IENr

) MEDICAL RECORD - ANESTHESIA For use. form, see AR 40-66; the proponent agency iL .jTSG

ACLU-RDI 1634 p.79

AIR L/Min N20 1/Mi n

COLLOID-0'

BLOOD-

0 Warmed RMAR KS 0 Warmed

0 Warmed

EST BLOOD LOSS • .SSES:..: URINE -

o2 L/Min SINGLE DOSE DRUGS-MARK ON GRID WITH NUMBERS & E TER IN REMARKS

Ri D Warmed

Specify)

MEL AL RECORD - ANESTHESIA For use form, see AR 40-66; the proponent agency is .,ISG Mialillar70111M111.11gthalliniffaill."

11111111.111 MEI

luau IIIIIUVRIMMIENINIII MENNEMININEMII WIMINENONIMIN Vt ml

INIME NIPASICLOIM/I EMIGIMEM 2[1:More: RiMPIMIKVIIMIIIESBM11111132116faiMil CM12150110161101011r1WINFIIVININIII MOM

BP/oth

ODE - SIil n). sist). Cfon)

f - breaths/min

E 02 (tow)

L4t.744,1

IMIN

MIE1111111111E ENIIII ItillINIMI ENEMEMENNE111111111111 IIIIN/VAIIMINIIIII 1111111111111111 INIIMMII IIIIIMMINNEMESINEEMIIIIMIMINEEINEMININIMINEMEEMI 111111111111111MENI IMMEIMEN1111111.1111MOMMIIIMI MR MIIIMIEME MEMO IMMINSIMIIIIIIII 1111111•111111111MEI 11111111111MEEINEE 1111111111MEMI EMENIIIMMEMINIMMEINIMMIENIMINEN MEI 1111111111111EN WEEIEWIIIIIIIIII IMEMEMEMMENUMEMINENIMINIENIMMEENIMEN IIIIIIIIIMIIR 1171111MINFANINIIIIIIIRMEWAIIPAWNANFAIII NOMMINEMMENMEENFAMENZIMGMEMEIMILIENZINIIMENI

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11111 IMI11,41111

PACU ICU

OTHER

N-M Block (T/4)

Warming blkt

Mark with letters & symbols. EVENTS__a_ explain under REMARKS Position "-

PROCEDURES and CU.Codes:

PATIENT IDENTIFICATI

CONDITION:

Typed or

RESP-

RP-

Grade/Ra GEMENT:

ntubation route, blade, technique, comments

MEDCOM - 15920 I \'. 0 kr-ew

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Coda drugs with numbers, a e with lepers ...-

BP by cuff

V

A Heart rate

Resp rate

•

X-X ANES- PROC-0_0

ANESTHETIC TECHNIQUES: Describe block technique under Remarks

IICIELIMINETENVINIGOIMI • IMMUNE WARM

DOD-029309 ACLU-RDI 1634 p.80

11•111111/11MINTAIMMIPIIIII

7-

7-- =mon

V---

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1:e 34-17 - 51e.:44eds m avit 7

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imier r

eliCh Viefv-r1

VI. 4 41-e-oh

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SINGLE DOSE DR - ARK ON GRID 1111W0

WITH NUMBERS & ENTER IN REMARKS

LINE site Warmed Warmed

ri.00161/MIKMP " armed

Warmed

EST BLOOD LOSS

-

1 2

BP-

BP by cuff

V A

Heart rate

•

Resp rate

2

200

180

160

140

• 120

-04100ft '

BR (transduced) 100

T 80

TOURNIQUET 60

T

HR-

OK for PROCEDURE?

TIME- ) , ANES- X-X PROC-C>.0

VT - ml

f - breaths/min

20

Peak Mf pres I PEEP

:c.- .a 3 L- , A-1,`Tee

3 10"..t.44.3

171 jt

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MEDICAL RECORD - ANESTHESIA .nis form, see AR 40-66; the proponent agency L.

f4e:

LO CD

Z

I- 6"Z

o. z

gr.ri z

00 z 11

•

5 ,

4

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IIIIIMII11111 MeV 111011111•1111M1=11=111111111111111,1111111111111111177=11

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MIMIM

11M1111111114111t.M11..11111 il 11111111111

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110111151111,1imuunrirsiril:TTMETI

M MI 1011111111 61111111

VIM MEM= NMI Y/ MIMI IfitalliVA71 Illiniall•

MODE - S(son). A(ssist), C(on) B /Auto Cuff T CO2 (tort)

p .

rpo2 Steth- PC/ES e v CG Gas analyzer TEMP-site

N-M Block (T/4)

Warming blkt

Cony warmer

grAIONNE, .s rilfCrWanraw 1111•11M Lk-MUM OTHER

ICU

EVIEVIIIEMIMAIIMIRM116141 CONDITION:

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•

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Room End

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N.— PATIENT IDENTIFICATION: Typed

kritt ei i .6.4oLtni evi_ rZt-il-e."

CEDURES and CPT C des:

rim,ical facility

Begin End

/a5b

rfitia irtep entries: me, Grade/Rate, AIRWAY MANAGE intubation route, bled?: cluteli me s 7,4 se/ e-- /4 c

U Ready

E1/8,5 HNI ES: Describe block J,echnfque under Remarks

PROCEDURE / 5

LOCATION:

MEDCOM DATE:

•ave 3

DOD-029310

ACLU-RDI 1634 p.81

, • End

uu 1.

, ,rnumEammi

EIMMEIN_____11 11•11• WM= Tm,mErimg EIMmunglONI

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INITIAL DATA: 111111111111

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MODE - S( on), Alssist), C(on)

P6A . MEDICAL RECORD - ANESTHESIA . t

For use at this form, see AR 40-66; the proponent agency is , JTSG' : i ral.e...........___IMEEnimm1211111111WMINIIII TOTALS

Min .1.01.111111.11

1111

MI 1111101 ..mwt•Fm

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WITH NI-WIRERS & ENTER IN REMARKS

SINGLE DOSE DROOsmARK ON GRID n MU

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11157Mgmall111111•1111111111111 .11WHINIMIII■s11111 mu a %)

IMIIIIMIN111111111111111111111111=n1111111111111 FEMIMMIIIIINIII11111111111111111

EST BLOOD LOSS

ANES-PROC-0_0

IT 1- Li Warmed

Sp02 I%) F102 (Frc or ET CO2 (ton)

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ic

El Warmed

ID Warmed

Warmed

220

INI IIMINIIIINIIM 111111111111111111111111111111111111111111=11111 111 111111111111111111111111MINS1111111111 11111111111111.111Imull111111111111111

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6 INIMINIMINinimINNMEN6MIMNIII ME

IIIMENNIIIIIIINIMINMERMIN MIIIMMEMIIMMINIMI

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---------

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ikt

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fa)

b PATIENT IDENTIFICATION:

Typed or written entries: Na177e, Grade/Rate,

)e/A13/ea-s

DA FORM 7389, FR j cqp

Medical facility AIRWAY MANAGEMENT: /ryb.ation route. Wade, technique comment , commen clES TA-P1 A4

MIL A-D- •

, SURG ONS• 19 CO 0

\(D MEDCOM . - 1592

A4 CRYSTALLOID-

CID ca COLLOID-

BLOOD-

With numbers, events with !meters

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A

6

1•111 11111111111 2

Cc8 ci6sZT a. ANESTHETIC TECHNIQUES: Describe block technique under Remarks

6Er/A-

11111111111111111111111111111111111 _•■=1111111111111111111 11111111111111111•111111.1■ ......_m 1111111111•1

RESP-i .. a. Sp02. 7 CONDITION: r 41

oe.tiA

RP- ' Atiggsf,.. 4.4140 . OPRIM:

E121 Start End

PROCEDURE LOCATION: 4kz DATE:

/ 3 4 o3 46•

PACU Specify)

OTHER

Cony wanner Mark MTh letters & symbols. EVENTS, explain under REMARKS Position PROCEDURES and CPT Codes:

200

A 180

Heart rate 160

• Rasp rate 140

120 BR

Itransduced) 1 00 -L.

80

TOURNIQUET 60

DOD-029311 ACLU-RDI 1634 p.82

`A FORM 71s:us con

EVENTS, explain under REMARKS Position — 0-1 0-4 a...4 PROCEDURES and CPT Codes:

XMLL. PATIENT IDENTIFICATION:

Typed or written entries: Name, Grade/Rate, Medical facility

\n >'

Mark with letters a symbols,

PROCEDURE? ..

TIME- 0/35.

111111mmunumertratiffelliQ7 RS21111.111111.1■11111011111111111111 111-11111111INIIMINVIIIIIIIIIIIIIII MIN =II

111111M1111•11111111111111•1111111111111111111111111110101111111111111.11111■Erm UNIIIIIIIIIIIMINIMMIGNIMMIUMBEI

MINERSIIIIIIIIMMIIIIMUNI

Immiliall 11111finik7IIEMEIMIC111111.1111•111111111.1111111.111111111111111_ , .t,:m.;,

now ,_____Ionnummammemimmunummiumumaiman aummimonummumenamasseammonammonstionnav IIIIIMPARIZIMILIZAMIII111111111111111111.1101111111111

1111111111111011111111111141, 1111INIMNISINIMINNIUNIMICHNUMMISINIU

MMINKUNIINGL_IIMINIMESNI IIMAIWAIIIMINIIIIINIIIIMMIIIIIIMIL

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uum1101111111/BEIMIIMIIIII 11.111111112111111WAIELIMMENIMMINEIN_MENIENNIESEMMINME 111111MINIIWAIIIIIIIMIRIAIIIIIIIIIIIIIMIlm

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MINIMIIIMMIIIMISIMIIII MIMMINIMMEMINNIVINSWEIMBIEMNIMMEWNEMINSIMIMEIMIMMI 111111111110M1/111111111111111111111111111111111111 /11•111111111111111•111RIMIMMIll

111.11111111111MMEINIMMINSENISIMINNIERMINNIMMINI.____NIIIIIIMINI

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511r1;1111021KNIETtlitill1111111111111111.11111.1111.11111111 1111111

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11111.1111111110117111111111111111111111.1111111111.1111111111111111.11111111 111.1 II 111.111111111111111111.111111111111111111111111111111111111111111111111111111.1 II II 1111111111.1■1111.111111111111111111111■111111111•11111•11111.11 NETIMml 1111111111111110.1111■111.1■0111111111.1111Mum MIMI I N ....................ummiummomm Ism

orf .....1 Will 110111■11■1111111IIIMI Emma'

OK for

11111111111111

MODE • S( on). A(ssIst), C(on)

02 Li Min SINGLE DOSE DRUGS-MARK ON GRID WITH NUMBERS & ENTER IN REMARKS

) MEDICAL RECORD - ANESTHESIA For use this form, see AR 40-66; the proponent agency is- ,j

)TSG

Mlrumr4 .11111111111.111111.1111111111111111111111111 .10...111.11....1111.11m....111111111111km

Y V / TOTALS

'&11 IS-.„___"____111MOIMIMAIIIIIIIII1111.1.1.111111111.111111111111111111=

11

.601.1111ffijill_MKOLIINMEINI.111.11.11111111111110111111111111111111 S

I( I 14) Adk.

N20 L/Min

1111.1111111111111111111

),44 As di-

EST BLOOD LOSS

ANES- PROC- 010

TOURNIQUET T

Sp02 (%) F102 (Frac or %) ET CO2 (toff)

BR (transduced) 1 00

BP by cuff

V A

Heart rate

•

Resp rate 140

❑ Warmed ❑ Warmed

❑ Warmed.

1111.111111•111111111MIIIPm111111MIIIIMININIMIN iffill1111MMERMINSUMMERsigitamitilamillin

IIIMINmaimm11111111111N111111111111111111M111•1111•11111•11•1101

00

1■111111■111.1111.11111.111111• FAIMIRM:11:""ma 312==

NglI11•111.1111.11111111•11•11•111111M rean • ii...1111111■111■1•1111•11111•1111111 Ilan ■111111.11•1111.1111■11111•1•1011•11111.11 IMIIIIINI111111■111.1111.11■111.111111111INIMIN 11=1111111111111•11111111111111

1 00 Od

MEDCO I

1 00

o ba

ANESTHETIC TECHNIQUES: Describe

block technique unde Remarks

C 4 ‘E 61A-L;-a /41-to 9,41 6t- Y AIRWA MANAGEmE,D/T: Intutin route, blade, technique,

comnients rAi-LAA, . 0 Tr P'z 654-_ rc.-q SURGE° • PROCEDURE

LOCATION: (--"I'R DATDATE:

RESP. Sp02- 9r BP- HR.

CONDITION:

Pilo) mu 3_ISpesify)

OTHER

09

Code drugs with numbers, events with /curers

414, p,

v4„09

on

di-c-(60).

CRYSTALLOI

CO LLOID- 5:a(

BLOOD-

116 11,463 Lit--4 1

mmo. wr,gr

03'4

End

ht nl

DOD-029312 ACLU-RDI 1634 p.83

101.1 o foo4- nitsi

/MEDICAL. RECORD - ANESTHESIA ■

this form, see AR 40-66; the proponent agency is , J

TOTALS

dB Yo NM .111111M1 11111111111111111.mi 41 /00 WM MI ■Muingal MIMI • ••••, Arcot % def IWO KIN lICZNIj - % e.t.

AIR UMin

SINGLE DOSE DRUGS-MARK ON GRID WITH NUMBERS & ENTER IN REMARKS

ite Warmed

❑ Warmed

❑ Warmed

❑ Warmed

STIV1B.0

BR itransduced)

TOURNIQUET

T —4/

s, Code drugs with number

Ci.a..4 "ID a( 04 /4! 1310

&2( vusk 4.44{1

mYc5i4,eri < iliec6L41

'Po YZ, *-

0 3 fri147

OK for PROCEDUR

TIME-

ANES- x-x

PROC-0i21

VT-ml

f - breaths/min

Peak inf pros / PEEP

MODE - S( on/. Afssist), C(on) riMMEEN. BP/oth F102 (Frac or %)

PACU ICU ISpsclo

OTHER Gas analyzer

CONDMON:

mom

trillfr71111111111 MIME

IIART line Sp02 (%) 1V711112111111RAIIIMI Steth- PC/ES

FilIMMEILIN1011111i1111;11111 11=45 •

N-141 Block (T/4/ MIR NM

Icony warmer Begin

Mark with letters & symbols, EVENTS_, explain under REMARKS Position PROCE URE Co s:

ANESTHETIC TECHNIQUES: Describe block technique under Remarks

ION: Typed nr written entries: Name, Grade/Rate, al facdity

T CO2 (torr)

TENT IDENTI

r}I AY MA

*pr,148---

MEDCOM - 924 1 1_t

GEIsiENT: intubation rgii% bleott tespniipe, cRInTent Ags

6.414.- 7 U44,1

DATE:lcAu. t)z,

DOD-029313

N20 UMm

02 L/Min

ACLU-RDI 1634 p.84

..earigmanyg

Age .7j2 DAYS MOS

PRoPosED PaocEDuRE: suRoicAL seRvicE: NPO SINCE:

ututc00: ETON:

DRUGS:

PAST ii SiL

ST Cartnovescular:

Hypertension N Y Angina NY

Neuropathy Other

GiydeC01091al : Pregnancy N Y Other Significant Mr:

N Y N Y Familial kw N Y

MI N Y CVA NY Other N Y Puhrionary System :

Asthma N Y

Ehonchitia/URI N Y COPD N Y Other N Y Renal System:

Acute/Chronic RF N Y Gastrohrtestinal: flepa01i5

N Y festal Honda N Y PUD/GERD N Y Endocrine System:

Diabetes N Y Steriods N Y Thyroid N Y Neurological:

Sokrures N Y C lercred N Y N Y

Time: ?1'e

SEDATION KEY:

1. MINIMAL (AnsidiYsis) Patent responds norm suy to verbal commands

2.MODERATE (conscious whom) Proem responds PerlresoftdaY to verbal commands alone or acoornpanied by light tactile sumulason.

Airway assistance is not necessary. 3. DEEP

SEDATION/ANALGESIA. Patient responds ourPcwahrfir_ following repeated or painful

stimulation. Ainver easiesinse insY be nftesaary. 4. ANESTHESIA.

Paderd does not respond to painiutstiartriation.

POS-ANESTHESIA EV ALU ( ) NO APPARENTANE D Nom (NON ASU) PUCATIONS OTHER

f ) Regional (Specify):

discussed with INFORMED

CONSENT/COUNSEUNG

STATEMENT: Plans, alternatives and risks of anesthesia The

\f) nd Signed:

CP giti inuferstand a agrees. Questions answered.

ANESTHETIC PLAN: LOCAL MAC

$ NPO Since

iteLGeneral Intubalion

including death have been explained to and

PATH MEDCOMjr1.5925 PrOViOUS edition is — _

Agammiterca

( ) n ordered as prdnied

U. U.

PREMF-DICATIONS: No Yes (0 fins) /CC

. mg IV itt PO . m g 111 04 PO

mg IV IN PO

AMME..r.paylljam H13/HCT: WA: OTHER:

13I

3 g 7$ o/

Skjned: Date:

Patient identificaUon: (Ward) (Ca Z-

IS bier Crl UCXC..DOS AMC Form

DOD-029314 ACLU-RDI 1634 p.85

Age t'SDAYS MOS PRoPosED_ PR sum-mu

NPO EMICE:

gocsACCO: Eron

DRUGS:

( ) orderall .Praninci

• .1

ASA Physica/ State 1 2 • —Z-a/LB HT: ALLERGIES:

PAST SURGIJANESTHETIC

0 5 E

O MA -6---it4; cut

N Y N N Y 14 I,

Ny

Sex (

Signed:

NST ) NO

T

(4, rt. Arti riANIF • t. KCI.4., 13 OS tr if ) ( )

PREMEDICATION.% None Yes (0

Ms) /CC • trig IV DM PO • mg IV IM PO • Ing IM PO

megmli2exmagal

HEVIICT (m: ER:

.1 3

St-11-05

120

ord s1.0 to Si

PAST Cardiovascular'

Angina NYPartension

NI CVA

I *Pulmonary System: Asthma Bronchitis/URI

C-1 COPD Other

Renaj Sy

numes/ChronicEP N Gastrointestinak fiepstftis

N Mita, Honda N PUDERD N Endocrine System:

Diabetes Steriods Thyroid

N Seizures

Ny NeuroPethY N Y Other N Y Gynecological :

Pregnancy N Y °Mar Significant Hx: N

Pamirs, IDC N Y

O.?

N N N N

N Y N Y N Y

• ,

-ST-A-T2C F-foce

SUPORMED COMENT/COUNSEUNG STATEMENT:

Plans, alternatives and risks of

ANESTHETIC PLAN: f ) LOCAL ( ) MAC

with the

.7 • .1 Cd)A4g,a-

n.

net nd ■• •

Regional (Specify):

meraser

ANEsTNenc comPucancsis ) OTHER

(NON SU)

Lt(4-2,

gned:

Vent Identification: (Ward)

Date: Time: Hrs

111'9 (6') ti C Fain, 2300 (Revised) 15 Mar 01 MCXC•DOS

NPO since

SEDATION KEY:

1.ANNINIAL (Ansioirsis) Patient responds nummey to verbal commands

2.MODERATE (conscious sedation) Patient responds pulpeeetuuy verbal command*

aione or accompanied by light tactile stimulation. Ainvay irssistance is not necessary.

a DEEP SEDATIOPIIANALGESIA. Patient

responds purposefully following repeated or painful stimulation. Airway assistance maY be necessary.

4. ANESTHESIA. Patient does not resew./ es painful summation.

including death have been explained to and

Tune:

PATE? MEDCOM - 15926 edition is obit....

DOD-029315 ACLU-RDI 1634 p.86

0

NPO Since

SEDATION KEY:

1. MINIMAL (Aritiolysis) Patient responds normatiy to verbal commands

2. MODERATE (conscious sedation) Patient responds purposefully to verbal commands alone or accompanied by light tactile thmigation. Airway assistance is not necessity.

3. DEEP SEDATION/ANALGESIA. Patient responds purposefully following repeated or painful stimulation. Airway assistance may be necessary.

4. ANESTHESIA. Pasant does not respond to painful stimulation.

trecnidiRAL ASSESSMENT ilSedatiog/Angiataild Sex ( ►

( ) FEMALE , ASA Physical State 1 2 5 E PROPOSED PROC

J 6- -ale ; Clk,, feeLca4"-vvr: 2010/1.13 HT: A IN. SURGICAL - ALLERGIES: /1/ Oft NPO SINCE:

ANESTHESIA PLAN OF Age a 63 DAYS MOS

PREOPERATIVE PAST MEDICAL HISTORY/SYSTFJAS REVIEW Cardiovascular:

Hypertension N Y Angina N Y Mt CVA Other

I *Isulmonary System: Asthma

r- , BronchitisAfill

064-11 COPD Other

N N N N

Y

V

Renal System: Acute/Chronic RF N Y

Gastrointesfinal: Hepatitis N Y Hiatal Hernia N Y PUD/GERD N Y

Endocrine System: Diabetes N Y Steriods N Y Thyroid N Y

Neurological: Seizures Neuropathy Other

Gynecological : Pregnancy N Y

Other Significant itt:

Clk N Y N Y N Y

BAgM

TOBACCO: ETOH:

DRUGS:

CURRENT MEDICATIONS: ( Et ordered as premed

PREMEDICATIONS: None Yes (CP Hrs) /CC

mg W al PO mg W WA PO mg IV IM PO

J_ABOFIATORY STUDIES:

HB HCT: /

OTHER: pr 'err inert WA:

c1 3

41-D

9-11-01)

8-10-03

I20 9.(e.

ASSESSMENT PAST SURGICAUANESTHEI1C

Pain Seale 0-10 WENT • Teeth Id,-

Trachea TPU1Neck Oropharnyx Nares i -,*

CHEST: C -rfr -"`g'

CARDIAC: S 1 S

EXTREPAMES:

N N

FamIlial HX

N Y

0

ye ora

1. 0

ANESTHETIC PLAN: { } LOCAL { } MAC { ) Regional (Specify):

Mask ntubati

INFORMED CONSENT/COUNSEUNG STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to and

(PE (ArVatare9PL12,(:"42

2 -011 Time: Oa 6 7 firs

Signed: Date: Time: Hrs

Patient identification: (Ward)

WAMC Form 2300 (Revised) 15 Mar 01 MCXC-DOS MEDCOM - 15927 MI !MI RECORD COPY

cmvith =al g

09- • Cet/42,..1- E- nke nd and a . Ouestio

EVALUATION". • N SU) RENT ANESTHETIC COMPUCATIONS ( ) OTHER

Previous edition is obsolete * u.s. GPO: 2002-729483

DOD-029316 ACLU-RDI 1634 p.87

n

TOBACCO: ETOH:

DRUGS:

CURRENT MEDICATIONS: 0 la ordered as premed

0

ANESTHESIA PLAN OF C Age 4 a's DAYS MOS

PROPOSED PROC SURGICAL NPO SINCE:

kel2;14WRAL ASSESSMENT (Sedation/AnesthesIgl Sex cyrmALE ( ) FEMALE

' 6- -tzge CUL flac

tri

ASA Physical State 1 2 &it 5 E WI: _24Lei/LB HT: IN. ALLERGIES: hi_ ft

PREOPERATIVE PAST MEDICAL HISTORY/SYSTEMS REVIEW Carcknotscular:

Hypertension N Y Angina N Y YI N Y CVA N Y Other N Y

02 " I ttOulmonary System: L' Asthma N Y

br• 0 OS

6'I COPD. RI N YY Other N Y

Renal System: AcutatChronic RF N Y

Gastrointestinal: Hepatitis N Y Hiatal Hernia N Y PUD/GERD N Y

Endocrine System: Diabetes N Y Marrieds N Y Thyroid N Y

Neurological: Seizures N Y Neuropathy N Y Other N Y

Gynecological : Pregnancy N Y

Other Significant Fix: N Y N Y

Familial IOC N Y

fiAe

LABORATORY STUDIES:

H13/HCT: / WA: OTHER: pr. _0. z /err Lizat

3 2.1145

1). 41-0 38

g _10- 03

PRF-MEDICATIONS: None Yes (0 Hrs) /CC

▪ mg P/111 PO mg IV IM PO mg IV OA PO

'IS cc: 7.1

A.

ASSESSMENT PAST SURG/CALJANESTHETIC

Pain le 0-10

PHYSICAL

rl-r9

INATION/r

°. 3P:m HEENT - Teeth %,„. op;

► 2)201 Trachea

TMJ/Neck 303'4 Oropharnyx Nares iv , ", 1--*

CHEST: C-f} T.."/

CARDIAC: 5

EXTREMITIES:

IV Access: . Y Ulnar Filling:

BACK

NPO Since Ak.

ANESTHETIC PLAN: { } LOCAL { MAC Regional (Specify):

pr.-Genera Mask

INFORMED CONSENT/COUNSELING STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to and

tR-. "itafbotazwz . 1 2 -013 Time: Oq 6 7 Hrs

MEDCOM - 15928 m6.411=141 rttULIF40 COPY

Patient Identification: (Ward)

4114

WAMC Form 2300 (Revised) 15 Mar 01 bleXC-DOS

SEDATION KEY:

1. MINIMAL (Arndolysts) Patient responds nonneav to verbal commands

2. MODERATE (conscious sedation) Patient responds purposefully to verbal commands alone or accompanied by light tactee stimulation. Airway assistance is not necessary.

3. DEEP SEDATIOIi/ANALGESIA. Patient responds purposefully following repeated or painful stimulation. Airway assistance may be necessary.

4. ANESTHESIA. Patient does not respond to painful stimulation.

Previous edition is obsolete * U.S. GPO: 2002-729.283

DOD-029317 ACLU-RDI 1634 p.88

DOD-029318

tr U.S. GOVERN., MEDCOM - 15929

CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG

THE DOCTOR SHALL RECORD DATE,

TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. PATIENT IDENTIFICATION

PATIENT IDENTIFICATION


DAD i, FORM 1 APR 79 REPLACES EDITION OF 1 JUL 77, WHICH MAYBE USED. 4256

ACLU-RDI 1634 p.89

V

CLINICAL RECORD - DOCTOR'S ORDERS For use of this form. see Aft 40-66, the proponent agency is OTSG

SYSTEM IS USEO, WRITE PROBLEM NUMBER IN COLUMN IN

DICATED BY ARROW BELOW.

THE

DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM

ORIENTED MEDICAL RECORD


DAT OF ORDER

C..)



NIJRSING UNIT

PATIENT IDENTIFICATION.

MEDCOM - 15930

DOD-029319 ACLU-RDI 1634 p.90

IDE NTIFI CAT ION INDICATED IF PROBLEM ORIENTED

A T IENT

YSTEm IS USED WRITE

PROBLEM NUMBER IN COLUMN

BY ARROW BELOW.

HE DOCTOR SHALL RECORD

DATE, TIME AND SIGN E ACH SET OE ORDERS.

CLINiCAL RECORD - DOCTOR'S For use of this form ORDERS, see AR 40-66, the Proponent agency is OTSG

HOURS

NO.

rviZOICi-,'L RECORD

ORDS NOTED

siG/v

URSING Si

ATIENT

\)\ \,*\ \-\

UASING UNIT

ATIENT IDENTIFICATION

URSING UNIT

ATIENT IDENTIFICATION

URSING UNIT ROOM NO.

MEDCOM - 15931

DOD-029320 ACLU-RDI 1634 p.91

LI ORDER

NOTED AND SIGN

NURSING UNIT

PATIENT IOEN

NURSING UNIT

F ICATION


/RSING

-/ENT ID NT IFICAT/ON

a ,

i t

aw DATE OF ORDS vommilmi a TI E OF ORDE

f 1 0 0 ma HOURS1 or r a m a m m I m RI _a 1 In m • a or im . a , II a 1,1 I m 1„. „" • m • sr -- ... 1,•• I- 1.1- A i ''' • u i a -- - --- 1 i

TIME OF ORDER

11111111/Immumims DATE OF

NG UNIT

F"..4 4256 APR 79

MEDCOM - 15932

REPLACES EDITION OF 1 JUL 77, WHICH M. e•

CLINICAL RECORD - DOCTOR'S ORDERS

PATIENT IDENTIFIC rr

SYSTEM IS USED WRITE

PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. EM ORIENTED

MEDICAL RECORD

THE DOCTOR SHALL RECORD DATE,

TIME AND SIGN EACH SET OF ORDERS.

IF PROBL

For use of this form, see AR 40-66, the proponent agency is OTSG

DOD-029321

ACLU-RDI 1634 p.92

L CH

vi

'21 a MEDCOM - 15933

\0\


THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.


LIST TIME ORDER

NOTED AND SIGN


OATE OF ORDER TIME OF ORDER 944-, D3 l o °

7- C46. / 4,, Iz. G.-qt.-L.61941

\o

HOURS

11111 bt uc) -

FIDE R TIME OF ORDER

t "---3 Croc) HOURS

A N 1-9- /QS A.Okele 9- 0 tcci2_ pos a"--- 4 kt,Az4pec:. ID A3

PATIENT 10ENTIFiCATIO

NURSING UNIT ROOM N• ED N


TIME OF ORDER

NURSING UNIT

laj#1/

DA 1 FAOP IP19 4256

DOD-029322

ACLU-RDI 1634 p.93

CAD

■




NURSING UNIT

f-CA,Piv PATIENT IDENTIFICATION

NURSING UNIT ca:TCAA)


NUR̂,ISIN G UNIT

.14 C (4)


NURSING UNIT

141Z__ DA---, FAci4'19 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

ko C. L.t ) - tr U.S. GOVERNMENT PRINTING OFFICE: 1994-153.7in

MEDCOM - 15934

DOD-029323 ACLU-RDI 1634 p.94

HOURS


THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET

OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. PATIENT IDENTIFICATION

LIST TIME ORDER

NOTED AND SIGN

NURSING UNIT

PATIENT IDENTIFICATION DATE OF ORDER

1'5 TIME OF ORDER

HOURS

NU SING UNIT ,,__c___ ROOM NO.


NURSING UNIT

vt)


NURSING UNIT ROOM NO.

4256 DA:: FORM 1 APR 79 REPLACES EDITION OF 1 JUL 77, WH B USED.

0 1r U.S. GOVERNMENT PRINTING OFFicF• low . • MEDCOM - 15935

DOD-029324 ACLU-RDI 1634 p.95


THE DOCTOR SHALL RECORD DATE, TIME

AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.


NURSING UNIT


NURSING UNIT

GJZ PATIENT IDENTIFICATION

‘,/

NURSING UNIT


3` NURSING UNIT

FoRm APR 79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

0

It U.S. GOVERNMENT PRINTING OFFICE: IBM— awa.71n

MEDCOM - 15936

DOD-029325

ACLU-RDI 1634 p.96

THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICA770)' FOI use of this form. see R 40-407;

RECURRING ACTIONS, 0

nir

1111111 1111Limsami111111

FAII MILMELIEr" diallliar 12111111E 111111111111111111011111

1111111111rill 11012MISIF 11111U11111 Imo1111111a.m.11111111111111111111111111111

11111111111111111111111 11111111111111111111= 11111111111111111111111101 111111111111111111111 ■ 11111111111111111111111


ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES- D 8 9 10 11 12 13 14 15 E 16 17 18 19 20 21 22 23 N 24 01 02 03 04 05 06 07 DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED

USAPA V1.00

MEDCOM - 15937

DOD-029326

ACLU-RDI 1634 p.97

Verii by Initialing

Order Clark Date NUM*

THERAPEUTIC DOCUMENTATION CARE PLAN (NONMEDICATION)

SINGLE ACTIONS Date to be Dons

Mo jr 2003 Time to be Dons Inlriale

Aotwic\- ICU 2 - 0014+-1-t SuokotrA vio Yl(t I

e,4--pane I e, Pr/

6C, nom 1)6?-6'W rtat

ION

d-owsL

'Y1 et/J held

0930 0

nso

auX

d3c00307 090 coo

Order/ Clerk/ EA* oate Nurse PRN

ACTION, FREQUENCY

gaidOket Arles ,yPrn--

DEM PROPER COLUMN FOLLOWING COMPLETION TIMEIDATE COMPLETED

4"--** USAPA V1.00

MEDCOM - 15938

DOD-029327 ACLU-RDI 1634 p.98

DA FOIRP, , 1 OCT 78 EDITION OF 1 DEC 77 MAV RF I IED. MEDCOM - 15939

MERAPEUTIC DOCUMENTATION CARE PLANffirONMENCAHONA the one t a en is the Office of The Surgeon General.

For use of this form, see AR 40-407; Mo.49 Yrfok..

t; INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION MUNINIMINSMONSINkg•

RECURRING ACTIONS, FREQUENCY, TIME

VIktAs -.

HR DATE COMPLETED GIRL. ERIC/ Ur, T ,RSE

S

ALLERC ■ . YES PRIMARY DIAGNOSIS:

L-9a-s\-ou-4 ADDITIONAL PAGES IN USE:

r--7 YES n NO

PAGE NO:

ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES

D 8 9 10 11 12 13 14 15 E 16 17 18 19 20 21 22 23 N 24 01 02 03 04 05 06 07

USAPA V1.00

CUM :ECORD

DOD-029328

ACLU-RDI 1634 p.99

( -4\c ',(NON-MEDICATION. Mo _ .

SINGLE ACTIONS Date to be Done

i

Time to be Done

Time Done

) - •

Initials

a6, \-A) +,-, E:c (.6z_ (.:(1[2._ /36 Coco .r.M.A6 eAr.,- --tClbl-e_- IL ),--) 0--Q-cp,

7.__,,,___ c„,,--, , --1-01-ocu-4 12, 143D wo I-, f,c 0s-1-- op to

I ct Ain— (14 fitiivi

VeS tkii-e. pv.eAo p 0 agrs 1 ote 615 / Act-114.7_ ( 'f4"`) iii-3& gm 14/UV(' • i 1

(yreAhob.t.,, ar>ia:s ks t6---on

i ..

R

0


INITIAL P4OPER COLIAIN FOLLOWING COMPLETION 4 TIME/DATE COMPLETED

i

,

USAPA V1.00

MEDCOM - 15940

DOD-029329 ACLU-RDI 1634 p.100

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) I Mo Yr)

For use of this form, see AR 40-407; the or000nent acurc is the Office of The Suraeon General.

INMAL PROPER COLUMN FOLLOWING EACH II 770N DATE DISPENSED

6 : kr6- monnumnennali

0 Ir. mow 72ORN ,diMICITIMMICELAL 111=111111111111111111111111111111MINIA1111111MONME

Anwitoreacin- "dam poqmirdmremembni

.IMPIMEROMUMM

FMK0-11Bmw11/4/14;1°- . Ym" A

Imprommiimaszaiii plu■Imumm

• ErAitivinnirign 0111PREMV"177.-'111

CLINICAL RECORD


ORDER CLERK/ DATE NURSE

RECURRING MEDICATIONS, HR DOSE, FREQUENCY

n

ALLERGIES: p YES p NO


PRIMARY DIAGNOSIS:

A. 4 12ptetaiv cizo -F2c ‹ao 7--k4U KALIL,

ADDITIONAL PAGES IN USE:

AYES p NO

PAGE NO.

fpwAiiir DISPENSING TIMES


D 7 8 9 10 11 12 13 14

E 15 16 17 18 19 20 21 22

N 23 24 01 02 03 04 05 06

C 7ORM 4678, 1 FEB 79 EAMON AP 1 net- v? um EXHAUSTED. MEDCOM - 15941

USAPA V1.00

DOD-029330

ACLU-RDI 1634 p.101

THERAI-...LITIC DOCUMENTATION CARE PL-4 (MEDICITIONS)

SINGLE ORDER. PRE-OPERATIVES Omer

Cleric/ Date

Nurse

Yr113 Date to

be Given Time to be Given

Time Given

let ioir,Awk 3zs

f, a Ingrimmall

ISM

. Cleric/ PRN Date Nurse MEDICATION, DOSE, FREQUENCY

T ) 100.5

1111101111=131101111111 111111ESESPIIIIIP/' 11111EVIESP'

1/1111r ,ii411/111111 111111/111111kriAINE

11111111111111r

INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION TIME/DATE DISPENSED

ACLU-RDI 1634 p.102


D 7 8 9 19 11 12 13 14

E 15 16 17 18 19 20 21 22

N 23 24 01 02 03 04 . 05 06

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) For use of this form, see AR 40-407;

RECURRING MEDICATIONS, DOSE. FREQUENCY

Immo ■Isaft war-, Min 1111 EMT' NNIMECNIRS Lail IfIr ' _JIIIIMMINVIIIMM

ill 111 _ PLANir4 M1111111111111110

111164111111112iiiiiillifileir wei ifinpuilmmin

111111111L411E611114 111- ..1111i1112116 ERMIENIPIIIIII EMI UMW aummation immininiiimuom mu- inimpangammargrag _111111P1111111111 MellidaillinEINNMPAIMIEFAML iLEMILSN' 111111111111111 FAIERIF 1-'111111111111111

111111j1111111 1.21UPZEN111111 111/41111111111 mar- SEW A _ AIM BICTIUL 11111111111M11111 IIIIMMIIIIkadIIIIIIIIIIIIIIIIIIII

ADDITIONAL PAGES IN USE:

Ej YES E2 NO

PAGE NO.

DISPENSING TIMES

ALLERGIES: El YES


(ape...) p D 1( AR 9

tiO

DA FORM 4678, 1 FEB 79 EDITION OF 1 DEC 77 WILL SE USED UNTIL EXHAUSTED. USAPA V1.00

MEDCOM - 15943

DOD-029332 ACLU-RDI 1634 p.103

Date to be Given

04 Jet

ifiPt(5

Mo.

Tams to be Given

(000

Time Given

( o)u) 1c 4-i

fn-y_a___ r - aF.7,c)ct- )J5 oJer- 4 141--s

SCO rc A1S 'QS 7- ( n 6k-k)

---Verify by Initialing

Order Clerk I Date Nurse

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)

SINGLE ORDER, PRE-OPERATIVES

t

PRN MEDICATION, DOSE, FREQUENCY

MUM PROPER COLUMN FOLLOWING ADMINISTRATION . TIMEIDATE DISPENSED

USAPA V1.00

MEDCOM - 15944

DOD-029333

ACLU-RDI 1634 p.104

CLINICAL RECORD


ORDER CLERK/ DATE N E

MEW MI I=Filiaammulfr- MEIN St EMI=

Nlimmommo1111111111111 rs II EMI 111111111111111 MN 111111111 11 -MEM

limms.2 III ImariTaraMTPAPII111111111 EIMII

ell'. III

THERAPEUTIC'DOCUMENTATION'CARE'PLA For use of thi s form, see AR 40407 ; onent a..n is the •ffi e of Th eon Get,: -

INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION

iirrdIMERMMOMME DATE COMPLETED

_ MEI II o 1111111-

cicc W -T7 mils=

IP'IIII

Milli III

ALLERGIES: Ell YES PRIMARY DIAGNOSIS:

Y

Sl ADDITIONAL PAGES IN USE:

YES Li NO

PATIENT IDENTIFICATION: PAGE NO:

J6 ACTION TIMES

USE PENCIL. CIRCLE ACTION TIMES

o/) D 8 9 10 11 12 13 14 15 E 16 17 18 19 20 21 22 23 N 24 01 02 03 04 05 06 07

DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED.

t \

MEDCOM - 15945

USAPA vi.00

DOD-029334

ACLU-RDI 1634 p.105

Verify by Initialing

THERAPEUTIC DOCUMENTATION CARE PLAN 4011N-MEDICATION) Mo___


Time to be Done

Time Done Initials Order Date

Clerk rse

,

i.i'

.,

.

L

if I *

Order/ Expir Date

Clerk/ PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION ACTION, FREQUENCY TIME/DATE COMPLETED

, OA tocLOGY0

4%; +1\-e r,CAIOCO Per 1 1 ,)19__ , ..

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USAPA V1.00

MEDCOM - 15946

DOD-029335 ACLU-RDI 1634 p.106

CLINICAL

VERIFY BY INITL 4LING

ORDER DATE

RECORD

CLERK/ NURSE

Snikalig*:attladatala..1.

THERAPEUTIC DOCUMENTATION For use

the • • • onent - •

CARE PLAN (MEDICATIONS) of this form, see AR 40-407;

.1 is the 0' ce of Th - •L on Gen INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION

. 6 i

RECURRING MEDICATIONS, DOSE, FREQUENCY

FIR DATE DISPENSED

lq 1 Kt R

— - kkiq , .

--- a,., ,Occi1K-- p...-..,

— c-\--ec,V_ c'eSkiiikcAS xpill 0 g c:, t cc---

t o co t-,c- oc-to teocci k r/Numil &ci.-16.,tiva.s \23 Ariv nog --\-va zkr3

oc-k--LA...G_e_ck..-t1:23 12_ A‘ Iraq

11 ..." i(e

— Oree. coc-P-e. cracl. , , INg2011 vl icc 1 - cc kr k- F5

'c# -4-0 _--3-7t,-14\i,vidt.s gazil 0111

EIN7 71 g la lila Mang' cf

ALLERGIES: 1 1 YES WT; e PRIMARY DIAGNOSIS: t ,

S/P r V'gee 1.->15)-Novert 661.S.VCC---rOr•..t./

ADDITIONAL

YES

NO.

PAGES IN USE: t III EN NO

PAGE PATIENT IDENTIFICATION:

C__ 1 V

nit CAORill WIO i rro -sn ----- • -- - --- --- --- - -

DISPENSING TIMES


D 7 8 9 10 11 12 13 14

E 15 16 17 18 19 20 21 22

N 23 24 01 02 03 04 05 06

MEDCOM - 15947

L EXHAUSTED. USAPA V1.00

DOD-029336

ACLU-RDI 1634 p.107

Time Soluti

X-rays:

Criteria

220

200

180

160

7,44 \ •

Pre Op Meks

Time f' SaO2

F102

Methods

240

tipo nog

-0\ b '•

, LOS

140 eir

120

V V

V V V N./ V V

100

80

60

tvo∎

•

n. • A.

• •

40

20

•-•

RR

T Time

0- 41 s.0

1k4 ‘4:1

et lti

Pain (0-10) ar et 0 €5"

AI M &

P SC

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form see AR Oa: tht proponent agency is the Office of The Sermon General.


IV OR Intake: Crystalloid &TA Colloid

OR Output UOP EBL Meds/Times: —

Anesthesia Type (Circle vett , (.1)(14

Spinal Epidural • e Block

•_(•,1-• •r ►

OTSG APPROVED Mato

Drains Hemovac

NG . JP

T-tube

Pacu ntake Amount Site

By 1 V1

Labs:

MSO4 10 WAS.:X15 ) yistory

REPORT TITLE

Date: I I Time In: a Allergies: Tiro. Pre-op V/S: Procedures:


Trach

Infused

•

Post-Anesthesia Recovery score ADM 30'

DIC Acdvdy (2) Moves 4 Extremities

Moves 2 Extremities (0) Moves 0 Extremities

Airway (2)Cough. Deet breath (1) Dyspnea, united breathing (0) rPool!

Blood Pressure (2) SBP =4- 20 of Pre-op (1) SBP =/- 20-5D or Pre-OP (0) SBP 4- 50 of Pre-op

Consdousrvess (2) Fully Awake, audible Wing (1) Arousable to verbal or pain

Color a) Bassin coior s appearance (1) pale, mottled, jaundiced - .

(0) Cyanotic

Circulation (Pads < 5 Years) (2) radial Pulse Palpable (1) AlollarY PalPable, not radial (0) Carotid only reliable pulse

TOTALS: Mint be 9 or greater to D/C. otherwise needs anesthesia approval for DIC. •

Codes

AIRWAY A = Arnbu Bli= Blow-by M = Mask FT = Face Tent RA = RoomAir NC = Nasal Cannula

V/S X A-One BP

= Cuff BP

= Pulse

TEMP

S =Skin

0 = Oral A = Axillary T e Tympanic R = Rectal

LOS C= Cervical T =Thoracic L = Lumbar S =Sacral

z Pollen teaching done; Wound Care. Pain Management, T. C. & DB.. Incentive Spirometer, Comfort Measures Sa ety: SR up X 2, Falls Precaationg, Privacy Maintained

PREPARED BY

PATIENT'S ID I r N(Fortypedarwrinenacmep' Cost rithilr grade; date hospital or

❑ HISTORYIPHYSICAL



❑ TREATMENT

❑ ROW CHART

❑ OTHER ap.wri

DA FORM 4700, MAY 78

WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete USAPIC V2.00

MEDCOM - 15948

DOD-029337

ACLU-RDI 1634 p.108

p. (16- e- cvc, (AI SIVI I101A) 71(A la51 moth. Ls cri4 . i D 12. -A t01/1

v.1 .

pruARA cap kxis b. (-PRA ,hilikq 'E-Act(Anap Io I. NV/

pioRQ abrivEQ_D. OD he

L_ 6_ A

1-

CARDIAC RHYTHM

Time Rhythm S tomato? Rhythm Strip Run?

\\\

WAMC OP 173-E

Allergies: MEDICATIONS

NURSING NOTES

Time Pain Medication & Route - Pain By

P1e-f2 -tiptoed reniceilktMbsilsztak 1.

Time Site Cap T Color Refill

N UROVASC Range Sensory

Of Motion

4- fi Mm

15'

30' 45'

60' 90'

D/C

=MN V■./ rfAII 131=1111M11113311 MI WM Oa MEI • INIIIIMIETNI • rovarmium

Movement/S nsation: = present- = absent Temp:C = Cool, W =Warm Pulses: P Palpable, D= Doppler. A= Absent Color: C= Cyanotic, -

Capillary Refill: B = Brisk, S = Sluggish P = Pale, Plc= Pink

ECTIONS I Adm

Fund. Height

Lixtda Peripad#

Fund. Cond.

DRESSINGS Time Location Type Drainage

Adm MUM MINE= 1 30' 1.0LITTIA II $:\ V lirMIM 60' 241 __IIMI ."

VC AIME " I ' ri.a..11

PACU OUTPUT

t_k is- - POONA 7 1 Lift-a . -)61AA C V &1)(3)_ cix711.1W

PT fry,-A- (Li) )i)()M71.42 SA A

1.4.111euL1 41 th,i

0 .A ! • Itaibl A., . . • 1 A ,k aj .,,„ I „

15' 30'

45. 90'

DIC

11 1S" Time Source

(1, We' VOtty Color/Appearance

P9* -4 <0/14

Discharge Criteria: DateilAvS.. Time: r5- PARS: 9 BP: VvrK Y: en c HR: ile* RR: Wit Sa02C915? Pain Level at D/C 10-10): upiarb-&-cAtzclAwk._ Intake: ?IVO Output: t.

Additional Data: it,

Transferred To: Report Given To: Transferred Via: W/C Utter Gurney Ambulance Transferred By: j ;Pt. Cleared IAW Recovery Room SOP 8-3 Charge Nurse Signature:

Amount

3bo

MEDCOM - 15949

DOD-029338

ACLU-RDI 1634 p.109

Pre Op Meds /1 r te// Time A) 3 z go

//

ss 1 t

Sa02 „Do 00 at fey

F102

cta 4111V Methods

Histo r

200

180

160 V

V

V

140

V V

120

A A 0 A •

• A.

60

40

20

RR t2.

6°4

100

80 A 1 A

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of dis Wm. see AR 40.60; lire proponent mewl is the Office at The Segeo^ Central.

REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet OM APPROVED ,Date)

Date: 9-- - / 4)

b Anesthesia Type (Circle)). Gerelia ./2pinal Epidural Time In: i 4 . . .

OR Intake: Crystalloid //CO IV Sedation Nerve Block

Allergies: Al

Colloid Pre-op V/S: OR Output: OOP 70 .0 EBt. 70

Procedures: Meds/Times: -Tr- -.L., / t,,e10 (0 ^'9 145 0 5 , / 4 7;-

Pacu Intake

Time Soludon Amount Site By Infused

1236 NS (5 6 I— FA- at. tsoccr

240

220

X-rays: . Labs:

Drains Airway Nasal

NG

Oral ETT

T-tube

Trach Foley Other TLS

PostAnesthesia Recoveryscore Criteria ADM 30' DIC Activity (2) Moves 4 Exbwnities (1) Moves 2 Extremities (0) Moves. 0 Extremities

Airway (2) Cough. Deep WWI (1) Dyspnea. roiled breathing (0) Apnea

Blood Pressure .• (2) SOP 4- 20 of Prthop (1) SSP 2050 of Pre-op (0) SDP 4- 50 of Pre-op

I 1

2_ 2- 2/ Cireitheticti (Reds < 5 Years) (2) radial Pulse Palpable (1) Astilary palpable, not radial

(0) Carotid only tellable pulse

TOTALS: Must be 9 or greater to D1C, otherwise needs anesthesia approval for g

yl DIC.

Consciousness (2) Fully Awake, audble Ming (1) Arousable to verbal or pain

CNC( (2) lanseine coke' & montane (1) pate, mottled, jauncliced (0) Cyanotic

AIRWAY A = Ambu BB = Blow-by M Meek FT= Face Tent RA = FloomAlr NC = Nasal Cannula

V/S X = A-line BP

=Cuff BP = Pulse

TEMP S = Skin 0 =Oral A = Axillary T =Tympanic

= Rectal

LOS C= Cervical T =Thoracic L = Lumbar S= Sacral


Patient teaching done; Wound Care. Pain Management T, C, & DB.. Incentive Spirometer, Comfort Measures Safety: SR up X 2, Falls Precautions. - Privacy Maintained

PA firs

ertfrms •al or raerlicaf leak)

DEPARTAIENT1SERVICE1011111C

—7.04,14-1/

Name —last

❑ HISTORYIPHYSICAL



❑ TREATMENT

DATE

ts 03

0 FLOW CHART

❑ OTHER spew

DA FORM 4700, MAY 78

WAMC OP 173-E, (Revised) I Apr 01 (MCXC-DN) Previous edition is obsolete USAPPC WIC

MEDCOM - 15950 JI

DOD-029339

ACLU-RDI 1634 p.110

Discharge Criteria: Date:/ 06 03 Time: t 23°1141 PARS: I BP: Vtgleil. T: HR: RR: I? Sa02: V%) Pain Level at ,DIC 10-10): 0 Intake: t Uct Output: Additional Data: Transferred To: Report Given To: Transferred Via: Transferred By: Cleared IAW Reco Charge Nurse Signa

act) Ambulance


1-10 Medication & !Insane

Route Pain 1-10

I/E By

N UROVASCULAR Time Site Range

Of Motion

Sensory .

P Cap Refill

T Color

Adm Pig $04.- Niit r I) vi 17- 15' It v. it lit 01, k 4

30' ti k I, U _

k W. k

45' 14 0 k k if it 0

60' 't if '- P it P. 4

90' Il t■ If P 1, 1, A

DIG N 1. It P N k ,,

Movement/Sensation: + = present,- = absent Temp:C = Cool, W =Warm Pulses: P= Palpable, D =Doppler, A= Absent Color: C= Cyanotic,

Capillary Refill: B = Brisk, S = Sluggish P= Pale, Pk =Pink

C-SECTIONS Adm 15 30' 45' 60' 90' DIC ,

Fund. •Height

Lochia

lilt:-

4\t Peripad#

Fund. Cond. -

DRESSINGS

Time Location Type Drainage

Adm 111D (i) Le Aee VI -6/ 30' atti ik VI il- .1 A

60' "---

D/C it)* V. it t*: .0. PI

NURSING NOTES

PACU OUTPUT • ...

Time Source Color/ arance Amount

t1,30 Pm. Mk

CARDIAC RHYTHM

Time Rhythm Symptomatic? Rhythm Strip Run?

I

1 WAMC OP 1 71-E

MEDCOM - 15951

DOD-029340

ACLU-RDI 1634 p.111


P IDENTIFICATION first, middle; grade: date:

Pre Op Meds Histo Time

Sa02

F102

220

200

180

160

140

120

100

60

40

20

tt

RR

X-rays:

Labs:

Airway (2) Cough. Deep breath (1) Dyspnea, knifed breathing MAPIlea

Blood Presses (2)SBP 20 of Pre-op (1) SDP 4- 20-50 of Pre-op (0) SBP 4- 50d Pre-op

Consdousness (2) Ray &Yaks, audible

(1) Arousablelo verbal or pain

Color (2) Baseene color & appearance

(1) Pale. mottled. jaundiced (0) Cyanotic

Circulation (Pads <5 Years) (2) racial Pulse Palpable (1) Axillary palpable. not radial (0) Carotid only. .rekable pulse

Criteria Acthely (2) Moves 4 Extremities (1) Moves 2 Ed•ernities (0) Moves 0 Extremities

Post-Anesthesia Recovertacore ADM 30' DIC

4-40 inkfA('

DEPARTMBITISERVICEICUNIC a II IMIR so morsel

DATE

Time In: IV Sedation Nerve Block Allergies: OR Intake: Crystalloid dn Colloid Pre-op WS: OR Output UOP RBL, •4/01) Procedur : a Nit

Date: 6-5 Anesthesia Type (Circle)): General Spinal Epidural

REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet

17 1/44sirlines:

Far use of this fork see AR 40-56: the araparert seem of The Sullen Gear'. s7 tl haproin err MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA

(tetavp#0.1Ayi 10̀ OISE APPROVED Wary

g 0 itith-S-4

Pam Intake Time

Solution

Amount

Site •

By — Infused

TOTALS: Must be 9 or greater to DIC. otherwise needs anesthesia approval for DIC,

Patient teaching done; Wound Care, Pain Management. T, C, & DB,.. Incentive Spirometer, Comfort Measures Safety: SR up X 2, Falls Precautions. Privacy Maintained

Drains Hemovac

NG JP

T-tube Foley

TLS

Airway Nasal Oral ETF

Trach

Other

Codes

AIRWAY A =Arnbu BB = Blow-by M = Mask FT = Face Tent RA RooMAir

Cannula

vis _ X r=A-lina BP

Cuff BP — Pulse

TEMP S = Skin 0 =Oral

Axillary .

T =Tympanic R Rectal

LOS C v. Cervical T Thoracic L Lumbar S = Sacral

Name —list,

❑ HISTDRYIPHTSICAL 0 FLOW CHART

❑ OTHER EXAMINATION ❑ OTHER &Awe OR EVALUATION

0 DIAGNOSTIC STUDIES

0 TREATMENT • RV'

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete

USAPPe 11.00

MEDCOM - 15952

DOD-029341 ACLU-RDI 1634 p.112

Discharg Criteria: Date: /Time: PARS: f6 , BP: T: HR: 6s RR: /5 Sa02: qg 241 Pain Level at D/C 10-10): Intake: Output: Additional Data: Transferred To: /C J1 Report Given To: Transferred Via: W umey ulance

Transferred B Cleared IAW R Charge Nurse Signatur

p‘P"


1 - 1 0 Medication & lIrraae

Route Pain 1-t0

I/E By

AI" itlig- il(.i° ,2 /U

. .

NEUROVASCULAR Time ' Site Range

Of Motion

Sensory P Cap Refill

T Color

•

Adm 0.Vllit.U.111e41.01111raffirtfl f

1 5 ' Mra rad111UN utowarargur

I rijI III PAL 1 I I IrE

30' 45' W 90'

D/C

Movement/Sensation: + = present,- = absent Temp:C = Cool, W =Warm Pulses: P= Palpable, D.-Doppler. A= Absent Color: C =Cyanotic, .

Capillary Refill: 13= Brisk, S= Sluggish P=Pale, Pk = Pink

C.-SE NS 1

Adm 15' 30' 4S 60' , 90' DIG

Fund. Height

Loctia Peripad# Fund. Cond.

DRESSINGS


Adm PT K. 70) . an

30' (-VIP. a 40_14-1,0 (km 60'

rOMMIIMMVSJAIIIIIM DIC

Vi /tee tiva l,dl P/4 6U 41/ dm ydutd ce9t;W

NURSING NOTES

PACU OUTPUT

Time Source Color/Appearance Amount

-.,:t 11^.('

,. :.::..."

CARDIAC R M

Time Rhythm Symp ' ? Rhythm Strip Run?

WAMC OP 173-E

MEDCOM - 15953

DOD-029342

ACLU-RDI 1634 p.113

DOD-029343

Rhythm Symptomatic?

OP "I 73 -F

a MEDCOM - 15954

Route

Site

111 . 1111111111111110.111111M1 -67

-

: cox AlllirrArit -, ,,ementiSensation: = present,- = absent Temp:C = Cool

v\I ,u-rn Pulses: P = Palpable, U.Doppler, A = Absent C = Cyanotic,

C ,••crila.-y Refill: 6 =Brisk, S = Sluggish P= Pale, =Pink

- Heigh

L.

P

-

adk

F Cond.

C-S CTIONS

MIK 30'

'WS

MUM Mill

Location

3:

C

DRESSINGS Type Drain

nD /Ice-

!doLJVI-flt‘e (Wei( 04k,tur)11-____51

)1t.

I/E By

Cap T

Refill Color

Pain

1 - 1 CI,

CARDIAC RHYTHM

Discharp.e Crit na: Date: Tirne: /171/5- BP:/4 T: 1-IFI: AI; Pain Level at INC (0-10): Intake:,_

Additinnai Data:

Transferred To:_---1-00- Report Given To:_

Transferred Via: IC

Transferred By:

Cleared )AW Recov

Charge Nurse Signatur

PARS:

RR: /I•• SaCJ2: blv

Gurney ten ,

ON-

_ O utput:

PACU OUTPUT

un, Ours Color/Appearance • Amount

ACLU-RDI 1634 p.114

1 110

`me tr .. "eroies:

'1-op V/S:

-,ocedures:

Anesthesia Type (Circle)): General Spinal Epidural

/62) IV Sedation Nerve Block

EBL /51-

rosy-Anestriesta tare Unit (PACU) Flow Sheet

OR intake: Crystalloid OR Output: UOP 4 Meds/Times: a Al

/ A WAN

• --'re 0

Time

Wlethods

1'20

700

Pact; intake

X-rays: Labs:

Time Solution Amount Site I nfuse.

Airway ̂ ' (2) Cough, Deer, torPtht:

ff

(1) Dyspnea, !knifed breathing / I (D) Apnea

Blood f'resstre (2) SBP 20 of Pre-00 (1) sEP •--/- 20-S0 of Pre-op (0) 51W5it of Preao

oz

Coe,etr;

AIRin,".AV

= s FT = Faae

Tent it =

NC = Nlanr

Ccnnul ,

TEMP

S =Skin

0 = Ore:

A = A xilter'; T = T yme.

=

LOS

C = T = Thornn• L lurnoa -S

DEPARTMENTISERVICE/CLINIC IGonlinue cm reverse/

DATE

, I Mu4 Name —lest

Meds History Inlin11111

511221111111111111111111 MINC/1111111111111111

IIIIIM1111111111111111111 11111111111111111111111=

1110111111111111111111111111111111 1111111111111111111111111111111111 1111111111111111111111111

111111111111111111111111111 1111111111111111111111110

1111111111111111111111.1111 11111111111111111111111MIMI

111111111111111111111111111M111 1142121111111111111111111=1 E10111111111111111111111111 01111•1111111111111111111111 81111111111111111111111111111 111111111111111111111111111111

1111111M1111111111111111111A1 011911111111111111111111111=111

laill111111111111111111111111111 1111111111111111111111111111111111111 11111111111111111111111111111111

1111111111111111111111111111111 111111111111111111111111111111111

111111111111111111111111111111

121111111111111111111111111111111 miallminans. 1111111Mninull

c'ean 10- I 0 WARIVIESIZIE LOS

Sa

ARF

ON titian

adridle: vatic: dare,- hoso favriry/

Drains Hemovac

NG JP

1-tube Foley

TLS

i60

'

20

T. C. F.

TOTALS: Must oe t or greater to 0/C. otherwise needs anesthesia approval (or D/C.

Circulation (Peds < 5 Years) (2) metal Pulse Palpable (1) Axillary palpable. not radial (0) Carotid only rqiable pulse

Color (2) Baseline av-ii 3 a ppearance (1) pale. mottled, pundirmd (0) Cyanotic

Consciousness (2) Fully Awaxe. audible

crYi ng (1) Arousable te verbal or pain

Post-Anesthesia Recove Criteria ADM 30' Activity

(2) Moves 4 Extremities (1) Moves 2 Extrsynities (0) Moves 0 tiitemiaes

score

•

D HISTORYIPHYSICAI



0 TREATMENT

0 FLOW CHART

❑ OTHER ts•efr)

Pa ient teachin • done; Wound Care. pain Manapemenl, OB.. Incentive S irometer, Comfort Measures

ty: SR ty X 2, Fats Precautions. Privacy Maintained

RIRM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) -- Previous edition is ohs;;

MEDCOM - 15955

DOD-029344 ACLU-RDI 1634 p.115

OTSG APPROVED (Date!

(ay.

Drains Hemovac

NG . JP

T-tube

TLS


Trach

1,..Zr4,V Pacu Intake

X-rays:

Labs:

Post-Anesthesia Recovery_score Criteria

• ADM 30' DIC Activity (2) Moves 4 Extremities (1) Moves 2 Extremities (0) Moves 0 Edrernakes

Airway (2) Cough. Deep beat (1) Dysixwa. Misled breathing (0)A .

Blood Pressure (2)SBP =1- 20 of Pre-op (1)SBP =/- 20-50 of Pre-op (0) SBP w- 50 of Pie-op

Z

2_

2 Consciousness (2) Fully Awake, audible crying

2-•• (1) Arousable b verbal or pain

-2-

Patient teaching done; Wound Care, Pain Management,

TOTALS: Must be 9 or greater to MC, otherwise needs anesthesia approval for 0/C.

Color (2) Baseline color appearance (1) pale, monied. jaundiced (0) Cyanotic

Circulation (Pads < 5 Tears) (2) raffia! Pulse Palpable (t) fedlary palpable. not radial (0) Carotid ordy rehab* pulse

Codes

AIRWAY A= Ambu BB Blow-by M 0 Mask FT = Face Tent RA = ROomAir NC • Nasal Cannula

WS - X =A-line BP

=Cuff BP 0 Pulse.

TEMP S= Skin 0 -brat A = Axillary T = Tympanic R a Rectal

LOS C = Cervical T us Thoracic L = Lumbar S = Sacral

T, C, & DB.. Incentive Spirometer, Comfort Measures Safety: SR up X 2, Falls Precautions. Privacy Maintained

DEPARTMENT(SEN1CFEUNIC

KA) 3 Name —last

Pre Op Meds

Time

Sa02 72" FiO2

Methods

240

220

200

180

160

140

120

100

80

60

40

20

Histo

\tptiodo eic

A A

A • • I P

A

A

A

tIP 41/

RR

T \ct fl ip r6


PREP

PATIENT'S I first, miallc grade; dare; despite/

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form. see AR 4018; the proponent arm is the Ma of The Suwon General.

REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet

Date: it Anesthesia Type (Circle)):Genca Spinal Epidural Time In: i O ft 7 IV Sedation Nerve Block Allergies: OR Intake: Crystalloid #610 Colloid _ Pre-op V/S: I P 5 ...... I i OR Output UOP id EBL /14.<4.14-14....,17 Procedures: eriTOPM Meds/Times:

t pa INVerS10 •

rwley

ID HISTORY/PHYSICAL

❑ OTHER EXAMINATION OR EVALUATION •

El cum= swim

1:3 TREATMENT

FLOW CHART

❑ OTHER e rr

DATE

41-Ce3_

OA FORM 4700, MAY 7 .8

WAMC OP 173-E, (Revised) I Apr 01 (MCXC-DN)

MEDCOM - 15956

Previous edition is obsolete USAPPC 5200

Z'

DOD-029345

ACLU-RDI 1634 p.116

Transferred By: Cleared IAW Recovery Charge Nurse Signature

MEDCOM - 15957

MEDICATIONS

Allergies: Time

1-Il) Pain &

nrAacie Route Pain

1..1n I/E By

4 0/05- V* 1-160q 3az 10 ,

NURSING NOTES

17/ 41.1r-el

012-12.4. Q. kg.o;v4A ,L.r. /ei)

-6-b" Per& 1-itE

UROVA LAR Time Site Range

Of Motion


T Color

Adm 1,14 IlriaMIEMIIIMICIIIIMIIIIMII 011garill1111V=IMILIMIIIIIMIIIIVall rearimmrarianimimm f le WA WIAN11111=111011 Mill WW2= EgalawAIIIIWANFAIIMIIPBMIMI

15'

317 45' 6°. 90' MEI NM WCZW—agal111116M11111EMIGO11104111/0-41

Movement/Sensation: + = present,-= absent Temp:C =Cool, W = Warm Pulses: P. Palpable, D= Doppler, A= Absent Color: C = Cyanotic,

Capillary Refill: B= Brisk, S= Sluggish P = Pale, Pk= Pink

C-SECTIONS Adm 15' 30' 45' 60' 90' D/C

Fund. 'Height Locittia Perlpad# Fund. Cond.

DRESSINGS


Mm 1.1-E JP 4-62 -A u .IA)

30' 1. (...Car- , l-e-., A4 -3A-1-

itle')",t4 60'

DM

PACU OUTPUT

Tim

S

Color/•earance

Amount

CARDIAC RHYTHM

Rhythm Strip Run?

Discharge Criteria: Date: li s me: PARS:

r/ BPM:M FIR:c07 RR: 7 SaO2: SSS

Pain Level at D/C (0-10): /&O Output:

Additional Data: Transferred To: / LA-) 2_ Report Given To: LY Transferred Via: WIC Ambulance

Time Rhythm Symptomatic?

WAMC OP 173-E

DOD-029346

ACLU-RDI 1634 p.117

MEDICAL RECORD•SUPPLEMEFITAL MEDICAL DATA use of this form. see AR 40-66: the Pigment agency is the Office of The Surgeon General.

Post-Anesthesia Cr. .e Unit (PACU) Flow Sheet OTSG APPROVED /Date! REPORT TITLE

Date: Lcig......i3 Anesthesia Type (Circle)): l'Artti. pinal Epidural Drains Airway Nasal

Oral ETT

Trach

Otter

itljel-7724-

Time In: I 11 IV Sedation Nerve Block Hemovac NG JP

T-bigce ole 3

Allergies: ------- OR Intake: Crystalloid -200 Colloid Pre-4::• V/S: 154 1 le / 1es' OR Output UOP / 6C2 EBL Procedures: 1 4- kl (DPA., .o. e 'IvIeds/Tirnes 5A.,

/4A9 ' A . S

Pre OD Meds History TLS

Time . .. 09 1 .

2t? c.".. I I

•

Pacu Inta ke

Sa02 71 i'i/' 41/4 • Time Solution Amount •Site • • By ;,Infused

F102 mom tam Liit9 ns A 7S >z- zog .o-400 Tr-C— , 4i, Methods .., 240

. ...

. •

220 X-rays: Labs: I

Post-Anesthesia Recovery score

200 s Criteria AT)M 30' D/C Codes

Activity (2) Moves 4 Extremities (11 Moves 2 Extremities (0) Moves 0 E:drenalies

. AIRWAY . .. A =Ambu BB'- Blow-by M

M Mask •

180

/‘ /N

160 .

. Ainvay (2) Crnigh, Deep breath (1) Dyspnea, limited breathing (0) APneti

' • FT= Tent RA !.RoomAir NC =Nasal 140

re '• •

• •

• (2)Blood PrenStang

W 4- 20 ci Pre-op. (1)SBP -4- 20-50 of Pre-op (0) SSP =I- 5,3 of Pre-op -

Cannula

V'S , , X = A-tine BP

120 ' ' '

100 • Consciousness (2)Fully Awaits, amble 01100 to Atousat4e to verbal or pain •

7-4

çJ

' =Cuff BP = Pulse

TEMP -

A A ,,,

1 ' ", • I 80 A

Color mor f2')Elaseine coke & appestarce

(1)pale. mottled, jaundiced (0) CYtirlelic .

= Skin 0 = Oral A = Axillary T = Tympanic

60

40 Circulabon (Peds < 5 Years) (2)radial Pulse Palpable (1) A palpable, not 'aerial (0) Carotid only reliable atilt.

,

R = Rectal

LOS . C =Cervical

-

20 TOTALS: Must be 9 or greater to D/C. othenvise needs anesthesia approval_ for D/C,

T = Thoracic L = Lumbar S = Sacral

RR li 0 •21 fp( T 974 - , — Time Patient teaching done; Wound Care. Pain Management. Pain (0-10) T. C, & DB,. Incentive Spirometer, Comfort Measures LOS Safety: SR up X Z Falls Precautions. Privacy Maintained

•

K41104110 on meow

44/4/

DEPARTiADIT)SERVICEICUNIC

(Cu 3 DATE

i6-4 ..... PATIENT'S IDENTIFICATION if typed ar cables give Name — last, first, middle: grade; date; haspital a r medical bate

01111111h,

i L. .,.. ( CA ' '

*,•-...) '

.

0 HISTORYIPHYSiCAL 0 FLOW CHART

■ OTHER EXAMINATION w OR EVALUATION ❑ OTHER glo


■ TREATMENT

. OA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)

Previous edition is obsolete GUMMI,

MEDCOM - 15958

DOD-029347

ACLU-RDI 1634 p.118

DOD-029348

DRESSINGS


Adm CS-,E i , .

KWOSINIP.

illi,, M 30' 1. 1 , e-

60' D/C _., 1.--z--- • , , • '

PACU OUTPUT

Amount Color/Appearance Source Time

CARDIAC RHYTHM

Time Rhythm Symptomatic? Rhythm Strip Run?

WAMC OP 173-E

Discharge Criteria: Date: /5-117-1/Time: 1467 PARS: /0 BP: 0/951 T. /7,41 H R: /lib" RR: 2, Sea?: fs2)

Pain Level at DIC (0-10):

Ambulance

Intake: •O Additional Data: Transferred To: Report Given To: Transferred Via: Transferred By: Cleared lAW Recovery Charge Nurse Signatur

Output

/c. u.)

IC 17 (..111le

MEDCOM - 15959

WE By Pain Route Pain 1-to

Time Medication & finsaoe

Allergies:

N UROVASC LAR Time Site Range

Of Motion


T Color

Adm (l) , 4 ,,, ' 1, al i

15' 30 ' Ira' 45'

OW ± PA=1111111

I •IIIM I. Wil Kg

I I RI . WMPF

. Mil I it , -

60' 1111

II ..

90'

DIC Moveme W =Warm Color:

Capillary

diral.WLIMII -71— Fryman:arm - 4 ation: + = present,- = absent Temp:C = Cool,

Pulses: P = Palpable, D= Doppler, A= Absent C =Cyanotic, ._

Refill: 6 = Brisk. S= Sluggish P = Pale, Pk =Pink

. _ C-.5ECTIONS Adm 15' 37 .45 60' 90' DIC

Fund. Height Lochia Peripad# Fund. Cond. _.

-

NURSING NOTES

/

A a ,

4.111F

MEDICATIONS

ACLU-RDI 1634 p.119

1 . REPORTING MW • .i . 2. MTF LOCATION ADMISSION AND CODING INFORMATION

For use of this form, see AR 40-400; the proponent agency is OTSG 1 2 3 4 5 6 7 8 (State or

Country Code.) A - T") 1 -SO ,_,T.

3 . REGISTER NUMBER NAME (Last, Fast. Middle Initial) (.1:6 -

0760.4*-

Ct

4. PAY GRADE 5. SEX

18

rn 16 17

9 10 14 15

if 1 6 . DATE OF BIRTH (YYYYMMDD) 7. AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION

1..) I.D 30 31 m6=-

GROUND 19 20 21 22 23 24 25 26 27 28 29 1

10. LENGTH OF SERVICE ETS 11. FMP 12. SOCIAL SECURITY NUMBER

35 36 37

#

El

UMW

39 pi 41 42 32 33 34

13. MARITAL STATUS HOUR OF ADMISSION

i 1

CH I CORPS (0( _ cts,

.4" ORGANIZATION (Active Duty Only)

46

i

14. FLYING STATUS 15. BENEFICIARY CATEGORY 16. IIP CODE OF RESIDENCE

53 54 55 56 57 58 59 60 61 47 48 49 50 51 52

17. UNIT LOCATION (State or 18. MOS 19. TRAUMA PREY. ADMISSION

71 YEAR 62 63

Country Code) 64 65 66 67 68 69 70

NO a: ..

20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD NAME/RELATIONSHP OF EMERGENCY ADDRESSEE

0 01(..., 72

ADMISSION

‘9 CEL) - (2■ ----- J.-C 0..*:;...... ADDRESS OF EMERGENCY ADDRESSEE (Include DP Code)

0 NAM . • •, • . • • - TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

013/L/

SFERRED TO 23. DATE OF DISPOSITION III YM MD Di

81 82 83 84 85 86 73 74 76 77 78 79 80 1

0 50 .?) I Z

24. CLINIC SVC - ADMITTING 28. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (Y YMMDD)

87 I 88

ild__. 27. LOCATION

89

A.._

_

OF

90

OCCURRENCE

91 92 93 94 95 96 97 98 99 100 101 102

DIMPAINIF411 • 28. MW OF INITIAL ADMISSION 29. DATE IAL ADMISSION IY YMMOD)

103 ------

104 (Battle Casualty Only)

105 106 107 108 109 110 111 112 113 114 115 118

FOR LOCAL USE

— t„. DY . G1) d'iM

- rP7.4171 ri P 0 &Ili II 4-5( 9 901, D

.3,54z . 3 7f- 3 9 •

DK ' r 3;-7-a 7 q&& (17)

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-._ e ©a ,

g 22. 1 ki, - zgy..zi 4c2P • .-/Z, /9 g/6, 0 Egv. ),

. t- goo, I

ADMITTING OFFICER 15/9118 E • - OF ADMITTING CLERK

....,

Dr y _ cnnw M - 15

DOD-029349 ACLU-RDI 1634 p.120

INPATIENT TREATMENT RECORD COVER! EFT

For use of this loan, ONE AR 40.400; the proponent open(

REGISTER NUMEEii

1 D 0 it-2D 0

2. NA, 3. GRADE

77-1-..: 0,0 ADMISSION REMARKS

4. LEX

!In

S. AGE

a_t_i \

6.. RACE

(9051-1 01 B. ETS 10. PREVIOUS

NU ADMISSION

1 FHIP

°I 1A

13 NIZATION

7-41:7Xt Pl_c6?31 14. WARD

-Z . C OA) 1—

15 FLYING STATUS

....--

16 OSG BEN

k7g

19 BRANCHICORPS

...!. 1.0

19 UICIZIP 20. TYPE CASE

6)14 21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION

7)1 /2,/,-- - or FRO/1'1 FA

22. HOURS OF ADMISSION

23. CLINIC SERVICE r

24. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE 25. TYPE DISPOSITION

KEE:. e TO fr;'' C-G9

26) DATE OF DISPOSITION

r-' "1'6,6 3 27.. ADDRESS OF EMERGENCY ADDRESSEE 0A41441 ZIP C4641 Th. TELEPHONE NO. . OATE OE THIS

ADMISSION

2 06 406. X003

ADMITTING OFFICER

2D. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY 4 30. DATE OF INTIM ADMISSION

E ch.,,,,,

32 UNITS OF WHOLE BLOOM COMPONENT TRANSFUSED

C017iireAd en %ram

33, CAUSE OF INJURY

34. DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES

963.5o q-/e0.0 Dx:Sif 6s-4) 7-10 /4-p T7 cf. 2

.... r2..s-9 1---,,,,- .......„, .v (---- -- /7_,,,.7, I l ___ Pa 549,6/

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c-, ,,t.,,,0 07 vi (7

,.. g6._ 93. c?

6 ._, • ,

C> ri (7:- ./:;) i 1)S 13.S7 , 1 6. ._.,

35. Total Days This Facility .

ABSENT SICK DAYS b. OTHE I c. CONV.IV/COOP CARE OATS

d. SUPPLEMENTAL CARE DAYS

C7

BED DAYS

iy 1. TOTAL SICK DAYS

/c7 36. Total Days All Facilites

ABSENT SICK Ors lb OTHER DAYS

700 j ___, COIN. LVICOOP CARE DAYS

A. SUPPLEMENTAL CARE DAYS

BED DAYS

./a TOTAL SICK DAYS

/ SIGNATURE OF ATTENDING 1.1E342.4l. OFFICER

DA 0 USAAPC If1.10

' $

MEDCOM - 15961

DOD-029350 ACLU-RDI 1634 p.121

ret end final dia

PHYSICAL EXAMINATION

k SI 1 e 1-2

.

(

(:"

it-t- /A/64c- kakis PROGRESS

AN

MEDICAL RECORD - ABBREVIATED MEDICAL RECORD

PERTINENT HISTORY. CHIEF COMPLAINT, AND CONDITION ON ADMISSION (Euler dor of admir,ion

y .) • --5/, Ls' CD-• G-tc

Y9lases

o t.1„e ---

0D4TE144/6 IDENTIFICATION NO. ORD AN I ZAT ION

WARD NO. or written en /Ant Name last. first, middle; grade; elate; hospital or medical facility)

RICO STER NO.

ABBREVIATED MEDICAL RECORD Standard Form Ma

4. GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS F1RMR (41 CFR) 201-45.505 OCTOBER 1975 539-106

MEDCOM - 15962

DOD-029351

ACLU-RDI 1634 p.122

RELATIONSHIP TO SPONSOR SSN/ID NO.



SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry) pegir DATE /

( (.e.7

PP , /I i• 41

APDFAVIIIIE %b

dd

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r ArAWArdiffairAW

,e0e7/,ftee ;v- 4

MEDICAL RECORD

STe's

PITAL OR MEDICAL FACILITY

ISOR'S NAME

nen entries, give: Name - last, first, middle; ID No or SSN; Sex; - - I rade.)



STANDARD FORM 600 (REV. 6-97I Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1 USAPA V2.00

MEDCOM - 15963

DOD-029352 ACLU-RDI 1634 p.123



DATE NOTES

ae ANwp3 4ctiv.eA --.\144 -6,0-r aboui- (coo • P4, —rpos\r-cite-21 -kir 140/

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t. f cVr Al• • ' r PC) 12-A- • atf 1(// lay 0 IIP Uric

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t i V '. tt f I I ' gpc&erni e/ : co or6 \ a et tv 1.-Ci,c- %-ula

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v c,f,e-) ):OrA(-) too:Li-M. (P LQ G qarA AO t6otle • 21G c‘ dir,ot(eicit/

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LAST FIRST MI or Other;

I

DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECO.,dt

,,S MAINTAINED AT s•

PATIENT'S IDENTIFICATION: 'For typed or written entries, prve: Name - ran. first, middle: 'REGISTER NO.

ID No or SSA ,: Sex: Dare of Binh; Rank/Grader

WARD NO.



Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(101

USAPA v1.00

MEDCOM - 15964

DOD-029353

ACLU-RDI 1634 p.124

LAST NAME 1 FIRST NAME I MIDE.:L E INITIAL 10 NUMBER

DATE NOTES

11 I 03 4 co.,,,oivv't 11 i ktit. ''' foi, 4, . _. A: / ittel/)‘ DOI 0 ft, 2f (f N /110,6 iyeed-wukt-t- ., orT ot4-1-h e kv.

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-tal F No-L1 Aild of iL 04 /at/Lap' moiLet 4sta,2401,/al P-0-4-00 a J. oh r iouctexAoff Aawid cv.,t,uuttf ado( oi

STANDARD FORM 509 iREV. 5/19991 BACK USAPA V1.00

MEDCOM - 15965

DOD-029354 ACLU-RDI 1634 p.125


PROGRESS NOTES I

D TE NOTES

7 ° A - (Ai A . Ji( At) el9V-a cit i( 0 lam,' rad.F gikca( cm/ V

9'cL .tfeti( -xioz, , _

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p

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19_30 or i 6., atkisri dad dittufitoti ckgiLapti 04/wao SOR'S ID NUMB

if f)060(

RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPON

LAST FIRST MI (SSN or Other;

DEPART3SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

MEDICAL RECORD 1

(

PATIENT'S IDENTIFICATION: (For Typed or written entries, give: Name - last, first, middle;

ID No or SSN; Sex; Dare of Birth; Rank/Graded

,„.

REGISTER NO. i

WARDNO .



Prescribed by GSA/ICMR FPMR 141CFR) 101-11.203(1;)1101

USAPA V1.00

MEDCOM - 15966

DOD-029355 ACLU-RDI 1634 p.126

LAST NAME FIRST NAME MICOLE INITIAL ID NUMBER

DATE 1 NOTES

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USAPA V1.00

MEDCOM - 15967

DOD-029356 ACLU-RDI 1634 p.127



DATE NOTES

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(SSN or Other) LAST FIRST MI


PATIENT'S IDENTIFICATION /For typed or written entries, give: Name - last, first, middle:

ID No or SSN: Sex; Dare of Binh; Rank/Grade/



STANDARD FORM 509 (REV. 511999) Prescribed by OSA/ICMR FPMR (41CFRI 10101.203(01110)

USAPA V1.00

l•

MEDCOM - 15968

DOD-029357 ACLU-RDI 1634 p.128

MEDICAL RECORD


PROGRESS NOTES

DATE NOTES

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LAST FIRST

IM

fSSN

1

DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY

.


t

PATIENT'S IDENTIFICATION: !For typed or written entries, give: Name • test. first. !roadie;

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STANDARD FORM 509 {REV. 5/1999)

Prescribed by GSAncrAR FPMR (41 CFR) 101 - 11.203(b)110)

USAPA v1.00

MEDCOM - 15969

DOD-029358

ACLU-RDI 1634 p.129

b((t2.J -

LAST NAME FIRST NAME MtC 'NITIALI ID NUMBER

DATE NOTES

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usApA vim°

MEDCOM - 15970

DOD-029359 ACLU-RDI 1634 p.130



DATE NOTES 4•... ....

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ll

MEDCOM - 15971

DOD-029360 ACLU-RDI 1634 p.131

mit NITIAL110 NUMBER

LAST NAME FIRST NAME

DATE NOTES

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MEDCOM - 15983

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DOD-029372 ACLU-RDI 1634 p.143

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DOD-029373

ACLU-RDI 1634 p.144

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PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name Date of Birth; Rank/Grade.1 Ilast, first, middle; ID No or SSN; Sex; REGISTER NO.

HOSPITAL OR MEDICAL FACILITY

NSN 7540-DD-634-4176


MEDICAL RECORD



(A) CHRONOLOGICAL RECORD OF MEDICAL CARE

Medical Record

STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1

MEDCOM - 15985

DOD-029374

ACLU-RDI 1634 p.145

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MEDCOM - 15986

DOD-029375 ACLU-RDI 1634 p.146



DATE 'NOTES

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MEDCOM - 15987

DOD-029376

ACLU-RDI 1634 p.147




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STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR 141 CFR) 201-9.202-1

MEDCOM - 15988

DOD-029377

ACLU-RDI 1634 p.148

SYMPTOM, DIAGNOSIS, TREATMENT, TREAT! ORGANIZATION (Sign each entry)

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DOD-029378

ACLU-RDI 1634 p.149

LIP41, • • IPA to A

SPONSOR'S NAME RELATIONSHIP TO SPONSOR SSN/ID NO.


Dare of Birth; Renk/Grade.)

WA N .


STANDARD FORM 600 (REV. 6-97) Prescribed by GSAJICMR FIRMR (41 CFR) 201-9.202-1

MEDCOM - 15990

b(0) - 2 P\- \\) NSN 754D-00434-4176


MEDICAL RECORD



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DOD-029379

ACLU-RDI 1634 p.150


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MEDCOM - 15991

DOD-029380

ACLU-RDI 1634 p.151




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Medical Record STANDARD FORM 600 (REV. 6 - 97) Prescribed by GSA/ICMR FIRMA (41 CFR) 201-9.202-1 USAPA V2.00

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MEDCOM - 15992

DOD-029381 ACLU-RDI 1634 p.152



DATE 1

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

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PATIENTS IDENTIFICATION: (For typed or written entries, give. Name - last, first, middle; ID No or SSN; Sex: Date

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Medical Record STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1 USAPA V2.00

MEDCOM - 15993

DOD-029382

ACLU-RDI 1634 p.153

NSN 7540-00-634-4176




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.


STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1

MEDCOM - 15994

DOD-029383 ACLU-RDI 1634 p.154


VITAL SIGJJS

TIME /24'0

I V1.0 BP /(0/ , d

PULSE

EMERGENT

AGENT

4NON-URGENT

CBC/DIFF

URINE C&S BLOOD C&S X

INITIALS

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RESP

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ACUTE ABDOMEN

SINUS

ANKLE R/L

C-SPINE

LS SPINE

HEAD CT

to cc

0 OC 0 co

NSN 7540-01-075-3786

MEDICAL RECORD EMERGENCY CARE AND TREATMENT

(Patient)

LOG NUMBER TREATMENT FACILITY


PATIENT'S HOME ADDRESS OR DUTY STATION ARRIVAL

STREET ADDRESS DATE (Day, Month, Year) TIME

CITY STATE ZIP CODE TRANSPORTATION TO FACILITY

SEX

An DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE

AREA CODE NUMBER - ITEM YES NO N/A ITEM YES NO

PRP ADDITIONAL INSURANCE

AGE HOME PHONE FLYING STATUS DD 2568 IN CHART

AREA CODE .?<

NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY

CURRENT MEDICATIONS „...er .

INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT

ITEM YES NO WHEN (Date) DATE LAST VISIT 24 HOUR RETUR N

n YES n NO

IS THIS AN INJURY?

INJURY/SAFETY FORMS

WHERE TETANUS

DATE LAST SHOT

•

COMPLETED INTITIAL SERIES

• YES ❑ NO ALLERGIES '

HOW

i . CHIE F COMPLAINT

d,a-e-1, (0

ORDERS

I 1 VULbt

TIME

VA

ORDERS . . BY COMPLETED BY TIME PATIENT'S RESPONSE

DISPOSITION

n HOME

,

n FULL DUTY


ri 24 HRS. n 48 HRS. n 78 HRS.


• MODIFIED DUTY UNTIL RETURN TO DUTY

CONDITION

IMPROVED

UPON RELEASE

UNCHANGED

• DETERIORATED

ADMIT TO UNIT/SERVICE REFERRED lot. TO WHEN

TIME OF RELEASE I have received and understand these instructions.

PATIENT'S SIGNATURE

PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID no. ISSN or other); hospital or medico) facility( 4allar

Oct) LI 10(n-2 411111-11111111111111

EMERGENCY CARE AND TREATMENT (Patient)

Medical Record

STANDARD FORM 558 (REV. 9-96) Prescribed by GSAIICMR FPMR 141 CFR) 101-11.203(b)(10) USAPA V1.00

MEDCOM - 15995

n ECG

DOD-029384

ACLU-RDI 1634 p.155

TIME 1,1-4.0

)(0-q PULSE t 2,2. RESP Cr"4-, INITI

ABO I PT/PTT

UA MSCC/CATH

558-1.11.14 \C;) —7540-01,07S-378B


(Patient)

LOG NUMBER

RECORDS MAINTAIN • AT

PATIENT'S HOME ADDRESS OR DUTY STATION ARRIVAL STREET ADDRESS„---7,

CI Y

__ o t.

DATE ID AY Mn •,,Yel i nk" u o, 0 •--1_ 40

STATE ZIP CODE TRANSPORTAT N TO CILITY

kg_e SEX DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE

AREA CODE NUMBER ITEM YES N/A ITEM fES

NO PRP ADDITIONAL INSURANCE

AGE

9. ilOMEIHONE FLYING STATUS DO 2568 IN CHART

AREA COO UMBER MEDICAL ORY OBTAINED FROM NAME OF INS CE COMPANY

CURRENT MEDICATI • S . 1W ' 40.11' coaS'

INJURY OR OCCUPATIONAL ILLNESS ------ ..--, EMERGENCY ROOM VISIT -

ITEM .V... YES NO WHE/4 )Date/ DATE LAST VISIT 24 HOUR RETURN

YES 0 NO IS THIS AN INJURY? WHERE TETANUS

ALLERGIES N1_3\ -IN

1-1 1

iumr remain surr _

INJURY/SAFETY FOR DATE LAST SHOT COMPLETED IRMA/ SERIES

III YES III NO HOW

CATEGORY OF TREATMENT VITAL SIGNS

❑ EMERGENT

❑ URGENT

NON-URGENT ENT

TIME

1 q4t)

MO

(t/

CBC/DIFF

URINE C&S CXR PA & LAT/PORTABLE

ACUTE ABDOMEN

}MCC/URINE/BLOOD/QUART

CHEM:

BLOOD C&S X SINUS

C-SPINE

LS SPINE

HEAD CT

CC Iii la

0

5

TEMP ICI"

'41T 1fi 1 (a

ANKLE RiL

ORDERS U PULSE OX

TIME ORDERS BY COMPLETED BY TIME PATIENT'S RESPONSE

DISPOS

4-1 HOME

TION

n FULL DUTY


n 24 HRS. n 48 HRS. n 78 HRS


MODIFIED DUTY UNTIL RETURN TO DUTY

CONDITION UPON RELEASE

IMPROVED •

DETERIORATED

UNCHANGED

ADMIT TO UNIT/SERVICE REFERRED

iii, ITO

11°11

WHEN •

• TIME OF RELEASE I have received and understand these instructions. PATIENTS SIGNATURE

PATIENTS IDENTIFICATION (For typed of written entries, give: Marna - last, fii-st, middle; ID no. ISSN or other); hospital Or medical facility)

111111110 \o,

EMERGENCY CARE AND TREATMENT (Patient) Medical Record

STANDARD FORM 558 'REV. 9-961 Prescribed by GSAJICIAR FPMR 141 CFRI 101-11.203(b1(101

MEDCOM - 15996

DOD-029385

ACLU-RDI 1634 p.156

TIME SEEN BY PROVIDER


(Doctor)

TEST RESULTS

TIME ACTION CONSULT WITH

PROVI

DIAGNOSIS

0 0 U

RESIDENT/MEDICAL STUDENT SIGNATURE AND STAMP

DER SIGNATURE AND STAMP

ABG/PULSE OX RADIOLOGY Check if road by radiologist

HIH

PLT

SUP 02

PCO2 SAT

P02

OTHER

RESULTS

EKG INTERPRETATION PT

APTT BHCG ETOH IGLU MICRO

PROVIDER HISTORY/PHYSICAL

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PATIENT'S IDENTIFICATION (For typed or written entries, give: Name — last, first, middle: ID ho. ISSN or other); hospital or medical facility)

EMERGENCY CARE AND TREATMENT (Doctor) Medical Record

STANDARD FORM 558 IREV. 9-96) Prescribed by GSA/ICMR FPMR 141 CFR) 101-11.203(b)(101

MEDCOM - 15997

DOD-029386 ACLU-RDI 1634 p.157

48 HRS. • 78 FIRS

RETURN TO DUTY

/2) r2 7540-01-075-a

:ES -104

MEDICAL RECORD RECORDS MAIN

EMERGENCY CARE AND TREATMENT

(Patient)

NA1."..OFINSURANCE COMPANY

ARRIVAL

/.

PATIENT'S HOME ADDRESS OR DUTY STATION

STREET ADDRESS

koLix)- =TY

STATE ZIP CODE

DUTY/LOCAL PHONE ,„,........M1CIfARY STATUS

AREA CODE NUMBER ITEM YES NO N/A

.GE PHONE ..„.HOdla._E FLYING STATUS

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1.IRRENT MEDICATIONS

dIJL

INJURY OR OCCUPATIONAL ILLNESS

ITEM YES NO WHEN (Date)

IS THIS AN INJURY? WHERE

4.EFIGIEs gbk,J C

INJURY/SAFETY FORMS

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DATE pay, Month, Year) TIME

S AoG Cr) TRANSPORTATION TO FACILITY

7e-E C/1 12-100--Y

ADDITIONAL INSURANCE

DO 2568 IN CHART

THIRD PART' INSURANCE

ITEM NO

DATE LAST VISIT

DATE LAST SHOT.....--COMPLETED INITIAL SERIES

❑ YES ❑ NO

24 HOUR RETURN

0 YES NO

TETANUS.

EMERGENCY ROOM VISIT

HIEF COMPLAINT

@0 ,i)&obt /fr.f LioutAl


PULSE

INITIALS

D EMERGENT

URGENT

rION-URGENT ID( th)

VITAL SIGNS

5

caC/DIFF —

URINE C&S

BLOOD C&S X

BHCG/URINEJBLOOD/QUANT CXR PA & LAT/PORTABLE

ACUTE ABDOMEN

SINUS

ANKLE R11.

C-SPINE

LS SPINE

HEAD CT

ORDERS

LSE OX / PATIENT'S RESPONSE MONITOR

COMPLETED BY ORDERS

iSPOSITION DISPOSITION QUARTERS /OFF DUTY PATIENT/DISCHARGE. INSTRUCTIONS

IODIFIED DUTY UNTIL

ADMIT TO UNIT/SERVICE

TIME OF RELEASE

WHEN

and understand these instructions. PATIENT'S SIGNATURE

:ONDITION UPON RELEASE

IMPROVED ❑ UNCHANGED

DETERIORATED

REFERRED

have received

FULL DUTY

EMERGENCY CARE AND TREATMENT (Patient)

Medical Record

STANDARD FORM 558 (REV. 9 -96) Prescribed by GSAPCMR FPMR (41 CFRI101-11.2031b)( 101

/Ft" typed or written enures, give: Name - last, first, middle; ID no. ISSN or other); hospital or medical facility)

AT1ENT'S IDENTIFICATION

MEDCOM - 15998

DOD-029387

ACLU-RDI 1634 p.158

CONSULTATION' 'EET MEDICAL RECORD I

REASON FOR REQUEST (Complaints and findings)

APPROVED )0CTOR'S SI ROUTINE 111 TODAY

72 HOURS ❑ EMERGENCY

TELEMEDICINE U YES u NO PATIENT EXAMINED U YES U NO IECORD REVIEWED U YE% U NO

r

'ROVISIONAL DIAGNOSIS

•

PLACE OF CONSULTATION

❑BEDSIDE • ❑ ON CALL

CONSULTATION REPORT

GNATURE AND TITLE DATE

DEPARTMENT/SERVICE OF PATIENT )SPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

(Ciontinue on reverse side)

LATION TO SPONSOR SPONSOR'S NAME (East, first, middle) SPONSOR'S ID NUMBE (SSN or Other)

, give: Name -- last, first, middle; ID no. (SSN [ REGISTER NO. ; Rank/Grade)

WARD NO. .TIENT'S IDENTIFICATION (For typed or written envies or other); Sex; Dare of Birth

Qvu

(ca' 4111/81

CONSULTATION SHEET Medical Record

STANDARD FORM 513 (REV. 4-98( Prescribed by GSA/ICMR FPMR (41 CFR) 101.11 2031b1I10)

USAPA VI .00

MEDCOM - 15999

DOD-029388

ACLU-RDI 1634 p.159

I ••RAOPER,-, .DOCUMENT ; :!4' -'' - Otto ; .!.:-

.4/.4

RE ..,.=., ' . 7.7";(0. --■'' .0. 'f, For use of thIsAtorm, see AR 40-66, the proponent agency is the office of The Surgeon General.

PIM . '. COT4.Th10,`OPERATING ROOM 1

NrAVr''T6 .• - '-'''.. . ''. '''.... BY an es-lhe,514. 2. PATIENT REVIEWED AND PROCEDURE

VERIFIED B pr /i& ( (s_ ,. - 2...

.3.- DATE - • TIME PATIENT ARRIVED IN SUITE

f 6 ALAG cr,., 0(055 4. PATIENT

TIME will NUMBER Z- 1


EXCITED 174 CALM • ANXIOUS U III CRYING U ANGRY U WITHDRAWN U OTHER (Specify)

COMMENTS:


ASSIGNED SCRUB

SSG RELIEF SCRUB

ASSIGNED CIRCULATOR

CPT RELIEF CIRCULATOR

!..7. POSITION AND POSITIONAL

N SUPINE

COMMENTS: I'l rrDp9)(

AIDS (Specify)

LATERAL: ❑ LEFT SIDE UP ❑ RIGHT SIDE UP

d paciatcl arty,bbarcis ,

U LITHOTOMY II PRONE • KRASKE

. .

IVA (3 al 1 (3n m py-ri- mai alai ru. 8. SKIN PREPARATION

HAIR REMOVAL U YES Ea NO PREP Si . 1OLUTION (Specify) Butadi nt So I SITE: (cto . BY WHOM:

- SITE: BY WHOM: ( (..C) — 12'

COMMENTS: Nin poD ityy,3 of ftitid5

DONE BY: ❑ OR M NURSING UNIT

METHOD: • DEPILATORY II RAZOR

❑ CLIP

COMMENTS:


-yr

Ai-- .... _................- V.-\41\A

(6<i> ) . • - , t.

LEGEND X Ground

V _ - IP-1P.-

-- Safety Strap = = = Tourniquet Pad

10. COUNTS


Other' • First Closing Count

Final Closing Count SCRUB CIRCULATOR

Sponge ❑ Yes al No

6.7.7

,."------------------------------ )

Needle Sharp • Yes No

instrument ❑ Yes No N Other ❑ Yes g No ......,„,------

11. PATIENT IDENTIFICATION (For typed or written entries Name - Last, first, mictYle; Grade; Date; Hospital or Medical

4- Mb b ( (t) CI'

give: Facility;)

12. ELECTROS RGERY DEVICE(S) (ESU)

0 ESU NO: 4 z

RI YES U NO

, 301 Re) GROUND PAD: BRAND l,( ,T e d -

LOT NO: 010q2.Z.4

is ESU NO:

GROUND PAD: BRAND

LOT NO:

■ BIPOLAR NO:

DA FORM 5179-1, OCT 87

REPLACES

MEDCOM - 16000

HICH IS OBSOLETE. USAPA V1.01

DOD-029389

ACLU-RDI 1634 p.160

; ;LI6APAN1.01:;:

MEDCOM - 16001 •

13. PROSTHESIS, IMPLANTS ❑ YES tl NO IF YES NAME: ID NUMBER; MANUFACTURER

ti

14, -,.:4Xeg4:41t.V'Tst,A4M MEDICATIONS /ORDERS ' 4#40w.:1-zeigtovs*Wvii4o4Oggatt IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES ■ ■

.MEDICATIONS SOLUTION so N DOSAGE TIME METHOD PREPARED BY GIVEN BY

[!16. kilocane .5". M artat n.4,, (a-

,.: WOUND IRRIGATION gYES ❑ NO, TYPE1S):

O .910 NS OTHER ORDERS TIME CARRIED OUT BY

PHYSICIAN'S SIGNATURE

15. X-RAY IN OPERATING ROOM IF YES, SITE

YES ❑ NO E •

16. LABORATORY SPECIMENS

SPECIMEN (S)

YES ❑ NO g NAME NAME

FROZEN SECTION (FS)

YES 111 NO M

NAME NAME

CULTURE 1C)

YES ❑ NO g NAME NAME

NAME NAME NAME

NAME NAME , 112 RIVING/IMMOBILIZATION (Specify)

A s 11 1 85 -fa, PZ

17. TUBES, DRAINS/PACKING YES ❑ NO ri TYPE/SIZE 1. 2. 3.

SITE 1. 2. 3.

19. ADDITIONAL INFORMATION

Wry° n ..111111111 etka rmy on aritte

Ants*h..imii

zQfictkicni I wed 20. OPERATION( I PERFORMED

k ID abd• LooLinci

21. PA D T

I .90) - TIME

0 1140. METHOD :::.: 4 - -;- ' 4:

U . : ,o_..,, ‘, :,

2 U SIGNATURE .. . .

V-) Q) - ,:. - ..--'6; ', •.! ,, ,‘Y . ; ,of . ,

IN - ) (C . z::ApAs-;k , tf -;, ,n,_..,_ ___ , 4.4, . • ,.I. ,. ;

REVERSE OF D.4 FORM5MPIWOCT 87

DOD-029390

ACLU-RDI 1634 p.161

511-119

NSN 7540-00-634-4124


POST- DAY

MONTH-YEAR DAY elk/

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(0) (•)

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180 104°

170 103°

160 102°

150 101°

140 100°

130 99°°

120 98°

110 97°

100 96°

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RESPIRATION RECORD

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PATIENT'S IDENTIFICATION (For typed or wri ten entries give: Name—last, first, middle; ID No. (SSN or other); hospital or medical faCility)

REGISTER NO WARD NO.

VITAL SIGNS RECORDS

Medical Record

STANDARD FORM Sit (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 16002

DOD-029391

ACLU-RDI 1634 p.162


POST- DAY

MONTH-YEAR DAY 41 7 - t.'. •

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JO.

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170

160

150

140

130

120

110

100

90

80

70

60

50

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HEIGHT: I WEIGHT --11.

JAI LENT'S IDENTIFICATION (For typed or wri ten entries give• Name—last, f rst, middle; IL) No. • (SSN or other); hospital or medical facility)

REGISTER NO

STANDARD FORM 511. (REV. 7-95) BACK •

MEDCOM - 16003

DOD-029392

ACLU-RDI 1634 p.163

511-119

NSN 7540-00-634-4124

MEDICAL RECORD VITAL SIGNS RECORD

HOSPITAL DAY

POST- DAY

MONTH-YEAR 6/1 DAY I 1 1 -5 1 ‘-z 1 It, - -1 II

P

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HO • • " • • • ' -12 * •la It • % Le • .

PULSE TEM

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150 1C

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PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last • first, middle; ID No. --.. (SSN or other); hospital or medical facility)

REGISTER NO '

VITAL SIGNS RECORDS

Medical Record

STANDARD FORM 511 (REV. 7-95) Prescribed by GSNICNIR. F1RMR (41 CFR) 201-9.202-1

MEDCOM - 16004

DOD-029393

ACLU-RDI 1634 p.164

MEDCOM - 16005

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DOD-029394 ACLU-RDI 1634 p.165

MEDCOM - 16006

DOD-029395

ACLU-RDI 1634 p.166

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ACLU-RDI 1634 p.167

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ACLU-RDI 1634 p.168

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DOD-029398

ACLU-RDI 1634 p.169

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DOD-029400

ACLU-RDI 1634 p.171

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ACLU-RDI 1634 p.172

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Ward/Section: /6U c?

• LABORATORY RESULT FORM (Subject to the Privacy Act of 1974 )

DOD-029403

DAT : REPORTED BY:

REQ cIAN(.

LAST, FIRST, 1%/11

(..-4 .. ir...„-,..,,(.

DA

7 3 TIME

/ SSN/PS • • N:

' fi emato ogy) " " Urinalysis Misc, &nip

"'E-- R GE TEST RESULT REF. RANGE TEST RESULT REF_ RANGE

12 (°- 1 0 Color INIII/11111 RPR

Negative o r;i541:vink

07-1.18-0 I API' N/A Mono Negative 154s

itient (M) -GI

Glu Negative : NUCrobio ogy .'nit_

.L ,1:.) ui : , Fin '0 • - 4 ., -' iv .:1 _ Bili Negative Source

111 lb 8.5 1 g,/,21: „; ,::—_-. :t 6 1,i g7.., 7 35.0 ;:,

Ket Negative Gram Stain

fi ;to

-.2' . H 7= r-. ! - ' ',.

(ib.- 9 21.0 -.1C

SG 'N/A Occ Bid Negative

29„. d; ., ,7 ., 1% :7 i:L 771e,-,, : .-. .•-!..'' -_ .,

Bid Negative E pylori 'Negative : ,II A A31) t4). . 12,6 ,i,i 1." rential

20.5 4

-1 reuti .1 0.13 A 1...10.'fv't:L 1.2 -.,:i

pH N/A Micro Parasites

Prot Negative Malaria

Urob 02- 1.0 0 & P

Lymph Nit Negative Other

Atyp 1mm Leuk Negative Aciei-osci*ie Urinalysis' .. _,

RBC Morph

HCG Negative

Spun Hematocrit

42- 52% (M) 37.47% (F)

CSF ., ,Blood.Bank

Sed Rate

. -

Cell Count


Other Directigen Negative ABO/Rh . . -• :Ctiagula tionSitudies. ' .. .

—

: .131064 Back Unit Crossinatcli • (MOST.SUBMIT SF.518 WITH .EYERY UNIT OF BLOOD :

, ; , - -.,.lit i UES' EI) , : • • ---:: : TEST

—r RESULT REF. RANGE T UNIT CROSS11L4TCII

PT 9.8-13.6 secs

APTT 21-34 secs

D dimer <20 ug/m1

FDP _......,...

<10 ug/ml

REMARKS;

MEDCOM - 16014

3 3

ACLU-RDI 1634 p.174

Wad/Section - 1_ç RE , _.. LABORATORY RESULT ORM

(Subject to the Privacy Act o 1974) LAST, FIRST,A41.

\'9 ( .,e,) — ,

SSN/P N.

a 61 Ai .. • _Ikinalya . :, • , .Misc; Serology- • ,

b6-)--- % ? 1111 ° V ,,, 06-T3-03

' 18:0P 11 r acieit

Ligits

AC 12. 0 *I , i t'i ' 3 lfli 4:5 10.5 4.64

TEST RESULT ' . RANGE TEST RESULT REF. RANGE

Color N/A RPR Negative

App

Glu Pf4Z____

if N/A

Negative

Mono

- Microbiology

Negative

00 6:00 14313 11, 9 9/dL 11„ 16, 0 ikt 40. t Z 35,0 ,,. b0, 0

Bili /1- i Negative Source

1 87.6 FL '` r,,,c 99 c, ..... .. rg 75, 7 L p 27.0 31.0

Ket /1.---e, Negative Gram

Stain M1-1:= 29.3 slidi, 7.0 37.0 i---it 176. .10'3,1tIL 150. 450.

SG ei 02s_ . N/A Occ Bid e

Negative

LIZ 10.2 44 7 LI ii 1. 2 4: x10'3/ti. 7

Bld Cd`i-e Negative H. pylori Negative

1. 3.4 pH 4-

N/A . Micro Parasites

Prot tio Negative Malaria •

- - Urob 0.2-1.0 0 & P

Lymph Baso Nit el---13 Negative Other

Atyp 1mm Leuk Negative : : :Microscopic Urinalysis ' •.. , , . • .. .

RBC Morph

HCG Negative 55A - /54 )-5 eloz

11 0— 5- 0 Xa4- • Spun Hem atocrit

42- 52% (M) 3747% (F)

CSF ' • . Blood Bank .. ,

Sed Rate Cell Count


Other Directigen f Negative ABO/Rh I

Coagulation Studies. -

- . :

.- -Blood Bank Unit CrOssinatch" , ; .• - . : - : , (MUST SUBMIT SF 518 WITH EVERY UNIT OI BLOOD : -; 7 • ' ! 1 .. ': !:

REQUESTED)

)TEST RESULT REF. RANGE UNIT TYPE CROSSMATCH

T 9.8-13.6 secs

APTT 21-34 secs

D dimer <20 ughni

FDP <10 ug/m1

REMARKS:

REPORTED BY: ANIL

.li-• izb' l D22T Eh LAB ID NO.:

MEDCOM - 16015

DOD-029404 ACLU-RDI 1634 p.175

CHEMISTRY REST', (Subject to the Privac Act o

Ward/Section: I

TIME SSN

Hgb

BUN

GLU

Creat

Hct

AnGap

Ca

Na 4

Cl

K

PH

PCO2

P02

TCO2

HCO3

s02

BEecf

.•

RESULT RE RANGE

.38-51% PCV

70-105 mgAll

0.7-1.5 mg/dl

8-26 mg/d1

23-27 romolii., (art) 24-29 mmoVl. (vea) 22-26 mmoVL (art) 23-28 =ion. (yen) 95-9g%

(-2) - (+3) [mold,

12-17 gfill

35-45malft(u0 41-51 mmHg(a) 80-105 mmHg (art) WA (veal

10-20 mmoVL

1.12-1.32 nunoVL

7.31-7.45

3.5-4.9

98-109nrimoUL

138-146 ol/L

Troponin- 1

Drug of Abuse

. .

ST ' RANGE

A T P

-.-- PICCOLO L= 06/03/03 17154 REP:•IACI: RANGE: MALE-['AHEM #: GENERAL (1U1'. DISC LOT #: OPER #: 1578 SIRIAL #:

ALB 2.9* 3.3 5.5 8/CL ALP

41

26-84 U/L ALT

89* 10-4/ U/L AMY

12* 14-97 U/L AST

141* 11-38 U/L TBIL 0.9

0.2-1.6 MG/DL BUN

13 7-22 MG/DL rAii 8.4

8.0-10.3 MG/CL 109

100-200 MG/11_ CRE

1.3*

MG/DL GLU

117

73-118 MG/OL TP

5.8* 6.4-8.1 8/CL

INST OC: OK CliEM GC. OK HEM 2+, LIP 0

ICT

TEST

Chemistry

TEST RESULT REF. RANGE

i616)Mtta Our 2ri

RY 12 3142AA4

DR #: 000 0000100684

i-5TAT EC8+

Pt

Pt Name:

.LB

LLP

LLT

kMN

ST

BIL

IGT

7P

77(

TES

r

TCO2

AnGap

Hct

Hb*

*via Hct

pH 7.418

PCO2 40.6 mmHg

HCO3

a•

BEecf • m m o l/L

Sample Type,.

06AUGO3 17:52

oper: L)

P hys i ci an :

Ser# 40763

Ver: JAM5046R CLEW A93

117 my/dL

19 my/dL

137 mmol/L

4.4 mmol/L

108 mmol/L

27 mmol/L

7 mmol/L

39 PCV

13 g/dL

CO2

I

LAB ID NO.:

REMARKS:

I REPORTED BY: or

61- MEDCOM - 16016

DOD-029405

ACLU-RDI 1634 p.176

_ Virr■-:J/Section : REQUES

02( 07 AST, FIRST, MI. '"

i^j Le, — _..,.„.

DA 7 , ,-..;

■ TIME Sub'ect

LABORATORY RESU T FORM to the Privacy A t of 1974

§§-ITF§E- • .•

, r. ematology) cpc • Urinalysis , ..Mi4 : T ro 0

n 't-7 R..

I2 , Li - L( 114 '..17-08- f)3

NGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE _

0 Color N/A. — RPR Negative

App N/A Mono Negative

-; 46 Pa

i tirr

s (NI)

( _ i.i t

Glu Negative - Microbio ogy

, LiV3/t , 0 Bili Negative Source

- - ■ i)e, ti.!:: L gldt: ,, i„, , - t 216 ?:

— I. ,...,:,.; 60, 0 F)

_Ket Negative ,

'

Gram Stain

i10 SG r . OCC Bld , Negative

' "di_ =7 , .1

---, 1% I xl(13/1d_

Bld Negative IL pylori Negative

150, 40, . vt_ g rential

20.5 ri i 4:1 y1(% ,;/ ; ,1 - ; j'" , .

.14

pH N/A Micro Parasites

Prot Negative Malaria ' -

Urob 0.2-1.0 0 & P

Lymph Nit Negative Other

Atyp imm Leuk Negative .11'Eci:oseopic Urinalysis' , .

RBC Morph

HCG Negative

Spun Hematocrit

42-,52% (M) 37.47% (I') 1II1l1BiiWIIllIal— ' Blood. Batik -

Sed Rate .

Cell Count


Other Directigen Negative .

ABO/Rh .

Coagulation Stildies. - ,. .... . ;.' - :, .Blood Bank Unit Crossmatch (MUST,Supiii: Sr518 WITH.EVERY UNIT OF. BLOOD

TEST RESULT REF. Riel.NGE UNIT TYPE CROSSMATCH

pT 9.8-13.6 secs

APTT 21-34 sees

D dimer <20 un1 -

FDP 1

<10 ug/mi _ —.- _

REMARKS:

REPORTED BY V4 DAT 1:

: LAB ID NO.: .

MEDCOM - 16017

aL 4'i

DOD-029406

ACLU-RDI 1634 p.177

MEDICAL RECORD ANESTHESIA WEICI. 21

WENN ILPFaMei !INN

RYSTALLOID-

COLLOID-

BLOOD-

Code thugs wRb numbers. events

yvelio lam

• I

OLS.

BP by cuff

V A

Heart rate

Resp rate

BP {transduced)

T TOURNIQUET

ADES- x-x PROC•®-0

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WNW MEM Inlirn WM MOM MEI MI

Atf

WRIWNIMINAMINAMI ; =MIMI BSA "vW: MINN P:! EMU WM'S=

MINIIMOUNI10111111=1111=11 MINIM UUI --(IFERMINNEISEMBREM ,:?;V: EME

MIME WMIM ME :*.n NMI WIEURNIMMUSEETA

MA 111.111101MI •

,$x

220

200

180

160

140

120

100

so

60

40

17--6 eQ.,

WI MEM 111111111=11 ZEN

MOE MORW:::::w: EME. WM: 04 MIME

arm '„ -mum •

PROCEDURES and CPT Cceotecle e

PATIENT IDENTIFICATION- ryPed or lownhin aaidos: Nam% eneckeRaga Modica facillly

WRAMC OVERPRINT 558 /9

1 OCT 99 MEDCOM - 16018 PATIFNT

'T‘

DATE/ t46-' ANESTHESU■

DOD-029407 ACLU-RDI 1634 p.178

DOD-029408

CLINICAL RECORD . DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG

THE DOCTOR SHALL RECORD DATE. TIME AND SIGN EACH SET OF ORDERS. k!F PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

DATE OF ORDER PATIENT IDENTIFICATION

U.S. GC MEDCOM - 16019 t-710

HOURS

LIST TIME ORDER

NOTED AND SIGN

TIME OF ORDER



NURSING UNIT ROOM NO. BED NO.


3E) NURSING UNIT

Dr FORM 4256 1 APR 79 REPLACES EDI ON OF 1 JUL 77, WHICH MAY BE SED .

)9 _

ACLU-RDI 1634 p.179

-

(0) CLINICAL RECORD - DOCTOR'S ORDERS

For use of this form, see Ap 40-66, the proponent agency is OTSG



LIST TIME ORDER

NOTED AND SIGN

cLC2-..k-■ c :

NURSING UNIT


DATE OF ORDER TIME OF ORDER

'9- Th., 6 D HOURS

NURSING: UNIT ROOM NO.


NURSING UNIT


NU R SING UNIT ROOM NO. BED NO.

MEDCOM - 16020

DOD-029409 ACLU-RDI 1634 p.180

\40 621) 2



LIST TIME ORDER

NO 0 AND

For use of this form, see A ft 40-66, the proponent agency is OTSG i k


DATE OF ORDER TIME OF ORDER

XFUCt 0 HOURS

c



NURSING. ,UNIT


NURSING UNIT


NURSING UNIT ROOM NO .

MEDCOM - 16021

DOD-029410 ACLU-RDI 1634 p.181

C ::.INICAL RECORD - DOCTOR'S ORDERS • For use of this form, see AR 40-66, the proponent agency is OTSG



re

DATE

R OF ORDER TOOL ORDER

'

/1...0 6 ) HOURS

LIST TIME ORDER

NOTED AND SIGN

.1c) k'1,, _ . A



•

..-4t. DATE OF ORDER TIME

1) l erji.v 5 1, 4° ' .( HOURS r

go A I'— — - V ; --,-1 w-P -V 1630 ,

t, 1 . a


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PATIENT IDENTIFICATION DATE OF ORDER TIME OF OR

..1.-- o3 1S555 HOURS

4— e 1 -1 [--, C 11...,-,...(2 7

r.r.,,, ./.. e". "."• C V ) 1.1 /".-7-7- 0 Lsie, "..ja 0-.4tC

NURSING UNIT UNIT ROOM NO. BED NO. , t

ma ' 'arar..■Km 4.7 "-%

i ..., 04721.C1/F ORDER ME OF ORDER

1

: 7


HOURS


14-, FORM 4256 1 APR 79

— -

REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

17

US. GO' MEDCOM - 16022 ) ) ; )

PIO

DOD-029411 ACLU-RDI 1634 p.182

li

MEDCOM - 16023

DOD-029412 ACLU-RDI 1634 p.183

PATIENT IDENTI DATE OF ORDER TIME FIC• TION

HOURS

L A HOURS

+ DATE OF ORDER TIME OF ORDER . ∎ \ -LIST TIME ORDER

NOTED AND SIGN


HOURS

o

NG UNIT

t (11.)

ROOM NO. BED NO. NUR-.

tit NURSING UNIT

(

FlOOM NO. BED NO.


NURSING UNIT

PATIENT IDENTIFICAT

03g N U Rc I N G S

D FORM 4256 1 APR 79

Fl

DATE OF ORDER TIME 0 ORDER

JUL 77. WHICH MAY BE USED.

Yr U.S. GOV - -

MEDCOM - 16024 '10

BED NO.

, d3IME OF ORDER

HOURS


THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER iN COLUMN INDICATED BY ARROW BELOW.

DOD-029413 ACLU-RDI 1634 p.184

PA SEtv7 II:1E14'71F !CATION

DATE OF OROER TIME OF

• „HOURS .,.

THE DoCTon :SHALL . RECORD DATE, TIME AND SIGN EACH SST OF ORDERS. IF PROBLEM pRIENTE MEI:VC:AL RE.Of.:ft;'•

SYSTEM is USED WRITE PROSLEIVI NuMBER IN COLUMN INDICATEDRN' ARr-tOW BEIJOW.

?

:.---,.........-.........o..A...,,,,,.....

' t + OATS OF : ORDER i

tiMEoP oficitri . i V't ,-, - ,IXt 1 'w..,-. 3-;:i

, la ?:- • i,o.ok.viez$ ' ''.. - ' ".

‘... 0 i.-i4r,rti--A;;v.

. /.0(

P

- .N-URSINq 1.11,JiT •noom . No.

•

CQN PA -rtEN.T rOskTIF.IPATION

•


Rir use of titi form, see AR 4.Q ,66,,Itis proponent agency is OTSG

•141--ri-___-____ ___

0.,!- (..1- 7,- ho . f

_.r..._ -,-, ..-■

z_.--)_..N.. _____. ..._ —......___ — .

,Y 1-a-y• I. L..1.,-: a ,-N:c.:..-. .-(.. .-,

t)ATE aF•OROEFt . TIME OF oricttil . i

.. .

mds6i4G Tirtirr Ft0610 sto

PATIENT • !PENT/I= !CATION

•

141.31iSiNGUivir- IA001,4 NO. - KED NO.

.PATIST4T 113047.1-..00ATION -DATE OF OREIER TIME OF • DER

fiCURS

•

•

NUSSTi4G UNIT ROOM NO 1SED NO.

DrsA

. i APR70 4256 REPLACES EOMON .OF 'I 41.11,. 77. WHICH MAY SE USED,,

FORM

MEDCOM - 16025

DOD-029414

ACLU-RDI 1634 p.185

FROM WO:

DATE OF-

tliroCAL ,RECORD--.-DOCt4541--011Dtk. , .

FOT u.se- at tbiri form, sed AR 4.0-60 the li`otionerit egenirf Is OTSG - _ THE DOCTOR SHALL. RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM. IS USED WRITE PROBLEM NUMBER IN COLUMN iNtlICATEo BY ARROW BELOW.

Li 71

Eit•ili AND

NURSIND-UNI

pA,71-thrir)ti.E TIPiCATION

.1.

'tiqung •

1 " "

••••••

••• . ;; ; 4 -: •:. •-•;;:t:a4

FIOOM . NO BED {tQ.

tJA

PATIENT IDENTIFICATION TIME CIF PRDER":'

pArENT'MENTP) A 190

eArFta TA Pfl" MEDCOM - 16026

DOD-029415 ACLU-RDI 1634 p.186

0_ •1 - 40,

71-4F: APEU

F?ECLIRIRINC FREGLi EN T )t0

• - - - • ARE PLAN (A:

-- •

CL:V..ZIA1N 2_-_7 C.H COMPLETIOY . . .

DATE COMPLETED

• -•

IMPARKIIMIM 111 2121111111112111

11110111111118.11111

11111111111111111111MMI A

11111M111311M111 1111111191MONMI

•

NEL' AA MINIE11111111111111111 Al1111111111111111111111111

11111111111111111111111111111 ENIMMIZEAME1 Md- NEGNEHE

zt_ 4 PlefilitLEZE1 '1 ACM

611111 fel NHS Mg

RISME hi MEI

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1 -9- . • '

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ACT!0•N TIMES

E PENL. ACTION TIME

y-)

E .6 17 1E 20 21 22 23

.!--; 2 4 0 02 C:2 OL-' OF.• 06 07'

.;1, •

MEDCOM - 16027

DOD-029416 ACLU-RDI 1634 p.187

Clerk Nurse

Verit y by Initialing

Order Date

16 ;II, d D .r-) 111=11111111112M1111111.41MMIN

74/

6.0

a7-45

MEDCOM - 16028

:•.•,--tV • '

St.

4134W;FA

•

•

•

C.

pi•LO• -


• INITIAL PROPER COLUMN FOLLOWING COMPLE770N TWIEJDATE COMPLETED

Order/ Expir Date

Clerk/ • Nurse

USAPA V1.00

DOD-029417

THERAPEUTIC DOCUMENTATION CARE PLAN MN-MEDICI770N)

SINGLE ACTIONS

_ Mt itlaoiik

hie)

Yr 2003

Initials Time Done Tme to be Doris

Deus to be Done

ACLU-RDI 1634 p.188

CLINICAL RECORD THERAPEUTIC DOCUZEIILAJIsONCA

'*RVrzftj -«=r.W. , RECURRING ACTIONS,

, see AR PLAN (NON-MEDICATION) - 2003


ORD DA Tr

CLERK! NURSE

.4-:;.K-;Ari

HR

1MTIAL PROPER COLUMN FOLLOVVING EACH COMP j ON

DATE COMPLETED FREQUENCY. TIME 63/111-112_130 ,

614 _ _ - -

5,tc,t+ :ides rA A 1

111

spc,

_ _ _ _ J Ail

Tit .iKe.- - ci •c .`d _

!gm ,,ill • 1 I

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ALLERGIES:

UA-

NO YES E] NO

• PRIMARY DIAGNOSIS: •

-5/P 65() L . Pi: ADDMONAL PAGES IN USE:

1,1 YES ED NO

PAGE NO. Oa


ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES 41111111.

b «c2_ - GI - D 8 9 10 11 12 13 14 15

E 16 17 18 19 20 21 22 23

N 24 01 02 03 04 05 06 07

DA FORM 4677, 1 OCT 78

EDITION OF 1 DEC 77 MAY BE USED. USAPA V1.00

MEDCOM - 16029

DOD-029418 ACLU-RDI 1634 p.189

Mo Yr 2003 Order Clerk

PRN ACTION. FREQUENCY

cv A ?o drq A)

-4); Ze PRA)

verit y, by Initiakng

Clerk/ Nurse

Order/ Emir Date

Al

CrL L THERAPEUTIC DOCUMENTATION CARE PLAN

(NON LMEDICA770N)

SINGLE ACTIONS

AaA;It. 2 Zo . /-dv de_ . r4f-NS-Cer- 40 _Z-6 10

Date

OOP

Cis Pr . erc-QCO-flAAV-Von(64. Ptcx-61,20

INITIAL PROPER COLIThfikl FOLLOWING COMPLETION TIME/DATE COMPLETED

Initials Date to be Done

Time to be Done Time Done

ACLU-RDI 1634 p.190

DOD-029420

A4 .1 ,,..immummassams,

amisom IMRE

- INN

•

DATE DISPENSED

• FHE,- 4. 49E1_11. DOCOMENTT ON CARE PIA:. ."7." ":" . E., ••••••

c.3PER. 14.`: Oa.":„PA-7.VG cri

I

it

RECURP ,4;::: hF

DOSE ECIJ

60 q hr-

• . r I. • • ,

cC:

11011r°41

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Alf17.- - -761ct, .e7,76(7:e4.

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MEDCOM - 16031

• . — .. •

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ACLU-RDI 1634 p.191

0:qt. -- z -

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c;erki PR ++: ------------------------- C.,181NG .d_DA:112\73-1 .??,4170A: Ntlf7;i• MEDICA -flON. DOSE FREGUENC.7.f." - TINIE:DATEDISPENSED

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rt/l,frp I tY2_>110, • • :.; .

-- r111/ "")-1 ft17- Pk 1'3

f

MEDCOM - 16032

DOD-029421 ACLU-RDI 1634 p.192

DISPENSING TIMES


D 7 8 9 10 11 12 13 14

E 15 16 17 18 19 20 21 22

N 23 24 01 02 03 04 05 06

VI: \VI-

ORD' DA

....:;oRD THERP sEUTIC DOCUMENTATION CARE PLAN (M MOM)

For use of this form, see AR 40-407; M 1. . 0_5 the proponent agency is the Office of The Surgeon Gen-

12 KI :IE

INITIAL PROPER COLO. :LOWING EACH ADMINISTRATION

RECURRING ....zOICATIONS, DOSE, FREQUENCY

HR . DISPENSED —_ , E

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100 IV -/-14_, cp /

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FEB 79 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA V1.00

MEDCOM - 16033

DOD-029422 ACLU-RDI 1634 p.193

THERAP.:IUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)

I Mo. Yr .

SINGL • ER, PRE-OPERATIVES L en

T me to be Given

Time Given Initials

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Order Date

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111111" MEDCOM - 16034

USAPA V1.00

DOD-029423

ACLU-RDI 1634 p.194

: ' nr Kt PLAN CORD , i i i+r t.) 0‘.. uuLU the .ldigpursie 1,-,-1,1 1.■ tivignf., ts,-etkf rl.tz 4t407., MEDICATIONA , ma y r

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Sga;;;;;Mlit:T. INITIAL PRO rPrl (P TIV FOLLOWING EACH ETIO COMP

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D 8 9 10 11 12 13 14 15

E 16 17 18 19 20 21 22 23

N 24 01 02 03 04 05 06 07

USAPA V1.00 A

MEDCOM - 16035

DOD-029424

ACLU-RDI 1634 p.195

E

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THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) M28 ia3


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Time Done Initials

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USAPA Vi .00

MEDCOM - 16036

DOD-029425 ACLU-RDI 1634 p.196

Aoel L 1 8-a-v

X ..RAY3 00510: Ls.03 aflAWIt•

Titol SC.I.UTION

INTAKE

*A19 SITE A. IMMO

OUTPUT

souace coup

Jr:fiddle;

(Continue an reverse)

DATE

❑ HISTORY/PHYSICAL



❑ TREATMENT

❑ FLOW CHART

❑ OTHER (Specify)

RECORD.-..SUPPLEMENTAL MEI For use of . de AR a0-68: the proponent agency Is the 011k., n aeon General.

REP°R"TtE POST•ANESTHESIA CARE UNIT (PACU) FLOW SHEET 62h

OTSG APPROVED (Dag

DATE : , _ r,-,-2 !':DTII MMA: GEN SAB . EPIDLIII , .4i- I I 6-►

Colloid ..mn-aysmos.c-no-cm•

TU IN: -7:40 MINE ELCa ri 5ED iTVI, (.., .

MCM,K: C tui L S rd . OI new: -2-s^o

•"\Dt bi)- c rITPUT: urine Output ESL

_AMMO-,Tr„I!!! ."1_ 4 :_7:c-ate ∎ k

r"0 2 1111=1 Ell REACT SCORE

Min OUT 2 2 SAT ritimairikagrarni , Ta -- IN 30

z20

019 by CO V Nom Roo -raw Mail. ACTIVITY San -, °...., O'nefoonions: 0 Vonnioor onsonual ,,-- . A 1 Sc.wa moo.. •e Mow SAIL" nommno

2 SOON. moo.: no 0,100Cot > raison 2 2

, (e,...r, 0 0.... MIMI WI, 1 lapel 1091. COMO iluann Mod Olt , c‘ 2_

_ 2 swans anal Mt moor IPA .r.-- 4. al

: I ANON ento gown lonoolonol Oen*/

ware. Mann eons I Z

ca. (AliwIcos 0 Aftion% tot, nan %Irmo soolmaosn

. im •

I

,

2 A

An

1C10eo1ooln ...0-- 5. 20% ors- arnsmossa Ism 1.-

In _ 11111WWW1AngeN . .4- BP' 50% ore- moms% ono Gk 1 Ilitalialgellv. REINIINMEMINII ...gm , Bp 20.50% 1101.-Nialthelail ie.*

.111 1111== 11111 . C•

MI11112111111 . --.:--------...-._

•.

Wows • 151noo oro.11111=1.111111 IIIIII EXIMITIEVILVIMEAMEVIIZATI 1 A.,,,,,,,houil•Niflast balms

. 11111111111141111111 kai► ll01•1111MIN - 2 ol wool

rr

1111/11.1.1.111 =I 11111 1111 MI •

2 Tanovas Is ) ‘Z- Z_. 1111 WIII NI= um

2° 47111101gIVEME104110111171 MonOnonows 0 nawary nom. <05 II

■ :.. i Tone 40- Oil

.,4,3 til116711111111LIIIZIKINIII 10 / z

tun do rule) 40'1

( f/or typed or written enrinst givc Name—last, first,

ospital or medical facility)

DA II% 4700

MEDDAC FBg OP 173 (Revised) 1 Nov' 89 (FISXC—NU)

MEDCOM - 16037

DOD-029426 ACLU-RDI 1634 p.197

INITIAL ASSESSMENT: LEVEL OF CONSCIOUSNESS: AIRWAY: OXYGEN DRAINS

Alert Nasal Hudson Mask ADX NEIMOViC -Responsive

(1:Eaeheal Oxygen Mist Jackson-Prat

Unrespon Nasal Cannula N/G Yracneostomy Foley '4444.40'

MEDICATIONS MONATUR L ( C4.- 3 - Z.__ ALLERGIEs:

472:' I-d—c- ....rue— I htemm.W ANT HY

Ar.-.14,-.-i . - "Ig...t."4/71._ 44frai....;..,42- . a-1-

.a-e-szew-Z./ IS-t-“- 614 i4.5646)0 21) c, 4

4 a/a-b. 2-4-4 1-4 e..„.ef.p.,e_644,...:. c) . ge" 3 os t._ , ‘1-,---- 9-4-4..------.4 .,-6,c....;. • - .

2),....A.,.. 0.),,,L.,,,,...:. .. ,$-,14,,, R,e(z-at

1*/24- icasv-A 9....: ell%

I- "(4......-.4 11,....4-01„ rly...41.q.....et

66_,...4 /G

.../

DRESSINGS SITE TYPE DRAINAGE

MILE ,-, 0 Z 1 OCI

ri--0-0C-4 0,--4 1 - - (

ew--71------ _-, ..........__.

„....._.,<_,,v_is..._.4.7 ,0_4_,..,-(_, ..

7 S , „..„---...-.4, ,..,.....r-,...._ 6.-12._44., CBI INFORMATION

...71....L221.. ...(...."1.4....ali,... ei.........ak.. TIME Cee IN URINE our COLOR URINE MI.

' 0-1/ .dv-ia--4.eit 3 . sa%ra i (i-e........-..... _42---,-):-----x„r-k cr,---1_a/- ielLA-i.-.... I 1„,,._ iAJci-ei_f eon /,,....5, , ,,

PACU FLUID TOTALS m..-- CRYSTALLOID IN ifL

i in;) Cc. URINE OUTPUT AA rLar.....i...a,-...

COLLOID IN DIES'S

,,,..- P.O NG TUBE

JP DRAMMEN:7VAC

TOTAL INTAKE (..SN.

TOTAL OUTPUT Y . •

-.re:, C,...■...31.... r• -11J DISCHARGE CRITERIA Time :&" t-Tr-Date : 8'41 % 3

REACT Score: VS: BP` R vi HR .7P- T 9-1.ki Cleared according to WARD 2-D SOP C-2 Charge Nurse Signature:

.

....._

MEDCOM - 16038

-41

DOD-029427

ACLU-RDI 1634 p.198

ADMISSION AND CODING INFORMATION

For use of this form, see AR 40-400; the proponent agency is OTSG

. "de.)

. REPORTING MTF 2. .... r LOCATION

1 l 2 3 4 5 6 7 8 (Stare or Country

' A "0 1 Oi t Z

3. REGISTER NUMBER 110 (44--) — 4 - • '

U4 V, 1 Rs,

4. PAY GRADE 6. EX

18 9 10 11 12 13 14 1§ 17 t

FAAJ ri . DATE OF BIRTH fY YYYMMOD) 7. AGE AT ADMISSION . B. RACE 9. ETHNIC RELIGION .

•

IM,U 5L11■1 19 20 21 22 23 24 25 26 27 28 29 . : 30

• 31 BACK-

GROUND

K 10. LENGTH OF . SERVICE ETS 11. PAP i 12. SOCIAL SECURITY NUMBER

IMOICIMITZ111311:111 43 44 45 32 33 34 35 36 kCA LL .--- :.

ORGANI2A110,1 (Active Duty °MY) ' 13. MARITAL STATUS HOUR OF ADMISSION

12 30

BRANCH I CORPS

--- -

. ------TA&ISt V

46

14. FLYING STATUS 16. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE

53 54 55 59 .60 51 47 48 49 50 51 52

17. UNIT LOCATION (Stare w Code)

1B. MOS 19. TRAUMA PREY. ADMISSION

71

AIAME/RELATIONSHIP

YEAR 62 63

Country 64 65 66 67 68 69 70

NO

20.

__----- 1

WARD OF EMERGENCY ADDRESSEE

72 ADMISSION

C-(."I I

Code)

1

ND LOCATION OF MEDICAL TREATMENT FACILf t. –6 ..... . TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

23. DATE OF DISPOSITION (YYMMOD)

. MTF TRANSFERRED TO

81 82 83 84 85 86 73 74 75 76 77 78.: 79 80

24. CLINIC SVC - ADMITTING 25. MTF TRANSFERRED FROM D)

87 88 89 90 91 92 . 93 94 . 95 96 97 98 99 100 101 102

0 0 S G'

27. LOCATION OF OCCURRENCE 211. MTf OF INITIAL ADMISSION D D/

103 104 Monk Casualty Only)

105 106 107 108 109 110 111 112 113 114 115 116

FOR LOCAL USE

VC- Sie GaA) TO AR D

i

ADMITTING OFFICER (Signory .

—

SIG

Ira A

MEDCO

DOD-029428

ACLU-RDI 1634 p.199

25. TYPE DISPOSITION '•—••■

28. DATE OF DISPOSITION

276. TE 28. DATE OF T ADMISSIO

19. ETS

24. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

REGISTER NUMBER 2 NAME NM,

y,...... ant

0 0 I ti 20S ER)) 4. SEX I AGE G. RACE 7.

rY) b _ 13. ORGANIZATION

APATIENT TREATMENT RECORD COVER SHEET For use of this form, see AR 40-400; the proponent agency is DTSG

11.

RELIGION ENGIN OF SVC

3. GRADE

10. PREVIOUS

AMSI6

14. WARD

BRANCHICORPS 19. 1.11C/ZIP

15. FLYING STATUS

OINE..•■•■

, -1-c co4Q 20. TYPE CASE

WIA 22. HOURS OF 23. CLINIC SERVICE

ADMISSION

21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION

27a. ADDRESS Of EMERGENCY ADDRESSEE Oncbada 24P Coda

■■••■■■■••

ADMISSION REMARKS

ADMITTING OFFICER

th428. ATION OF MEDICAL TREATMENT FACILITY 3

30. DATE OF INT IAL 32. UNI WHOLE BLOOD/ ADMISSION COMPONENT TRANSFUSED

31.

33 CAUSE OF IN/ urn Check if Continued on Rowse

DIAGNOSES/OPERATIOAS AND SPECIAL P °claws

a5cz--10 Lej Flaw a0631.46

7917

i. Total Days This Facility

ABSENT SICK DAYS

OTHER DAYS

CON/. LVICOOP d. SUPPLEMENTAL CARE YS CARE DAYS

BED DAYS

1 1

I. Total Days All Facilites

TOTAL SICK DAYS

ABSENT SICK DAYS

b. OTHER DAYS e. CONY. LV/COOP d. SUPPLEMENTAL BED DAYS CARE CARE DAYS 1. TOTAL SICK DAYS

NATURE OF ATT

OFFICER

RM 36 7, EDITION OF

EDCOM - 16040 USAPPC V1.10

DOD-029429

ACLU-RDI 1634 p.200

it iimpati i nisi i , pill er

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